Federal Practitioner

TOPLINE: COVID-19 infection is associated with a 25% reduction in cancer risk over 3 years among veterans who survived the initial infection. This protective effect was observed across sexes and racial groups, with stronger benefits seen in older patients and those with mild disease.

METHODOLOGY: 

• Researchers conducted a retrospective cohort study comparing Veterans who tested positive for COVID-19 between March 15, 2020, and November 30, 2020, to those who tested negative.

• Analysis included 499,396 veterans, with 88,590 (17.2%) COVID-19 positive and 427,566 (82.8%) COVID-19 negative patients, with mean (SD) ages of 57.9 (16.4) and 59.5 (15.8) years, respectively.

• Investigators utilized Cox proportional hazard regression models to determine the hazard ratio of new cancer diagnosis within a three-year follow-up period.

• Patient characteristics included age, race, ethnicity, sex, BMI, smoking status, and various comorbidities as covariates in the analysis.

TAKEAWAY:

• For patients surviving ≥ 30 days after COVID-19 testing, infection was associated with a 25% reduction in cancer hazard (hazard ratio [HR], 0.75; 95% CI, 0.73-0.77).

• The reduction in cancer risk was similar across sexes and races, with the exception of Asians, and showed greater decreases with advancing age above 45 years.

• Patients with mild COVID-19 showed the strongest reduction in cancer risk (adjusted HR, 0.72; 95% CI, 0.70-0.74), while those with moderate COVID-19 showed an 11% reduction (adjusted HR, 0.89; 95% CI, 0.83-0.93), and severe COVID-19 showed no significant reduction in cancer risk.

IN PRACTICE: "Regarding age, the incidence of cancer appeared to decrease with each decade of life in the COVID-19 group com­pared to that in the non-exposed group,” the authors noted. “This is surprising, given that cancer diagnoses typically increase with age.” 

SOURCE: The study was led by researchers at the Miami Veterans Affairs (VA) Healthcare System Geriatric Research, Education, and Clinical Center and was published online on August 25 in PLoS One.

LIMITATIONS: The findings of this retrospective and observational study should be interpreted with caution. Results may not be generalizable beyond the predominantly male, older veteran population. The 3-year follow-up period may be insufficient to fully understand long-term cancer incidence patterns. Researchers could not capture all COVID-19 reinfection cases due to testing occurring outside the Veterans Affairs system, including at-home testing. The impact of vaccination status and reinfection on cancer risk could not be fully assessed, as the initial study cohort was grouped prior to vaccine availability.

DISCLOSURES: The authors report no financial support was received for this study and declare no competing interests.

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

TOPLINE: COVID-19 infection is associated with a 25% reduction in cancer risk over 3 years among veterans who survived the initial infection. This protective effect was observed across sexes and racial groups, with stronger benefits seen in older patients and those with mild disease.

METHODOLOGY: 

• Researchers conducted a retrospective cohort study comparing Veterans who tested positive for COVID-19 between March 15, 2020, and November 30, 2020, to those who tested negative.

• Analysis included 499,396 veterans, with 88,590 (17.2%) COVID-19 positive and 427,566 (82.8%) COVID-19 negative patients, with mean (SD) ages of 57.9 (16.4) and 59.5 (15.8) years, respectively.

• Investigators utilized Cox proportional hazard regression models to determine the hazard ratio of new cancer diagnosis within a three-year follow-up period.

• Patient characteristics included age, race, ethnicity, sex, BMI, smoking status, and various comorbidities as covariates in the analysis.

TAKEAWAY:

• For patients surviving ≥ 30 days after COVID-19 testing, infection was associated with a 25% reduction in cancer hazard (hazard ratio [HR], 0.75; 95% CI, 0.73-0.77).

• The reduction in cancer risk was similar across sexes and races, with the exception of Asians, and showed greater decreases with advancing age above 45 years.

• Patients with mild COVID-19 showed the strongest reduction in cancer risk (adjusted HR, 0.72; 95% CI, 0.70-0.74), while those with moderate COVID-19 showed an 11% reduction (adjusted HR, 0.89; 95% CI, 0.83-0.93), and severe COVID-19 showed no significant reduction in cancer risk.

IN PRACTICE: "Regarding age, the incidence of cancer appeared to decrease with each decade of life in the COVID-19 group com­pared to that in the non-exposed group,” the authors noted. “This is surprising, given that cancer diagnoses typically increase with age.” 

SOURCE: The study was led by researchers at the Miami Veterans Affairs (VA) Healthcare System Geriatric Research, Education, and Clinical Center and was published online on August 25 in PLoS One.

LIMITATIONS: The findings of this retrospective and observational study should be interpreted with caution. Results may not be generalizable beyond the predominantly male, older veteran population. The 3-year follow-up period may be insufficient to fully understand long-term cancer incidence patterns. Researchers could not capture all COVID-19 reinfection cases due to testing occurring outside the Veterans Affairs system, including at-home testing. The impact of vaccination status and reinfection on cancer risk could not be fully assessed, as the initial study cohort was grouped prior to vaccine availability.

DISCLOSURES: The authors report no financial support was received for this study and declare no competing interests.

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

TOPLINE: COVID-19 infection is associated with a 25% reduction in cancer risk over 3 years among veterans who survived the initial infection. This protective effect was observed across sexes and racial groups, with stronger benefits seen in older patients and those with mild disease.

METHODOLOGY: 

• Researchers conducted a retrospective cohort study comparing Veterans who tested positive for COVID-19 between March 15, 2020, and November 30, 2020, to those who tested negative.

• Analysis included 499,396 veterans, with 88,590 (17.2%) COVID-19 positive and 427,566 (82.8%) COVID-19 negative patients, with mean (SD) ages of 57.9 (16.4) and 59.5 (15.8) years, respectively.

• Investigators utilized Cox proportional hazard regression models to determine the hazard ratio of new cancer diagnosis within a three-year follow-up period.

• Patient characteristics included age, race, ethnicity, sex, BMI, smoking status, and various comorbidities as covariates in the analysis.

TAKEAWAY:

• For patients surviving ≥ 30 days after COVID-19 testing, infection was associated with a 25% reduction in cancer hazard (hazard ratio [HR], 0.75; 95% CI, 0.73-0.77).

• The reduction in cancer risk was similar across sexes and races, with the exception of Asians, and showed greater decreases with advancing age above 45 years.

• Patients with mild COVID-19 showed the strongest reduction in cancer risk (adjusted HR, 0.72; 95% CI, 0.70-0.74), while those with moderate COVID-19 showed an 11% reduction (adjusted HR, 0.89; 95% CI, 0.83-0.93), and severe COVID-19 showed no significant reduction in cancer risk.

IN PRACTICE: "Regarding age, the incidence of cancer appeared to decrease with each decade of life in the COVID-19 group com­pared to that in the non-exposed group,” the authors noted. “This is surprising, given that cancer diagnoses typically increase with age.” 

SOURCE: The study was led by researchers at the Miami Veterans Affairs (VA) Healthcare System Geriatric Research, Education, and Clinical Center and was published online on August 25 in PLoS One.

LIMITATIONS: The findings of this retrospective and observational study should be interpreted with caution. Results may not be generalizable beyond the predominantly male, older veteran population. The 3-year follow-up period may be insufficient to fully understand long-term cancer incidence patterns. Researchers could not capture all COVID-19 reinfection cases due to testing occurring outside the Veterans Affairs system, including at-home testing. The impact of vaccination status and reinfection on cancer risk could not be fully assessed, as the initial study cohort was grouped prior to vaccine availability.

DISCLOSURES: The authors report no financial support was received for this study and declare no competing interests.

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

Male veterans with breast cancer may have a more difficult time receiving appropriate health care due to a recently revised US Department of Veterans Affairs (VA) policy that requires each individual to prove the disease’s connection to their service to qualify for coverage. 

According to a VA memo obtained by ProPublica, the change is based on a Jan. 1 presidential order titled “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government.” VA Press Secretary Pete Kasperowicz told ProPublica that the policy was changed because the previous policy “falsely classified male breasts as reproductive organs.” 

In 2024, the VA added male breast cancer (along with urethral cancer and cancer of the paraurethral glands) to its list of presumed service-connected disabilities due to military environmental exposure, such as toxic burn pits. Male breast cancer was added to the category of “reproductive cancer of any type” after experts pointed to the similarity of male and female breast cancers.

Establishing a connection between a variety of cancers and military service has been a years-long fight only resolved recently in the form of the 2022 PACT Act. The VA lists > 20 medical conditions as “presumptive” for service connection, with some caveats, such as area of service. The act reduced the burden of proof needed: The terms “presumptive conditions” and “presumptive-exposure locations” mean veterans only have to provide their military records to show they were in an exposure location to have their care for certain conditions covered. 

Supporters of the PACT Act say the policy change could make it harder for veterans to receive timely care, a serious issue for men with breast cancer who have been “severely underrepresented” in clinical studies and many studies specifically exclude males. The American Cancer Society estimates about 2800 men have been or will be diagnosed with invasive breast cancer in 2025. Less than 1% of breast cancers in the US occur in men, but breast cancer is notably higher among veterans: 11% of 3304 veterans, according to a 2023 study. 

Breast cancer is more aggressive in men—they’re more often diagnosed at Stage IV and tend to be older—and survival rates have been lower than in women. In a 2019 study of 16,025 male and 1,800,708 female patients with breast cancer, men had 19% higher overall mortality.

Treatment for male breast cancer has lagged. A 2021 study found men were less likely than women to receive radiation therapy. However, that’s changing. Since that study, however, the American Cancer Society claims treatments and survival rates have improved. According to the Surveillance, Epidemiology, and End Results database, 5-year survival rates are 97% for localized, 86% for regional, and 31% for distant; 84% for all stages combined.

Screening and treatment have focused on women. But the VA Breast and Gynecologic Oncology System of Excellence (BGSoE) provides cancer care for all veterans diagnosed with breast malignancies. Male veterans with breast cancer do face additional challenges in addressing a cancer that is most often associated with females. “I must admit, it was awkward every time I went [to the Women’s Health Center for postmastectomy follow-ups]” William K. Lewis, described in his patient perspective on male breast cancer treatment in the VA.

Though the policy has changed, Kasperowicz told ProPublica that veterans who previously qualified for coverage can keep it: “The department grants disability benefits compensation claims for male Veterans with breast cancer on an individual basis and will continue to do so. VA encourages any male Veterans with breast cancer who feel their health may have been impacted by their military service to submit a disability compensation claim.”

Male veterans with breast cancer may have a more difficult time receiving appropriate health care due to a recently revised US Department of Veterans Affairs (VA) policy that requires each individual to prove the disease’s connection to their service to qualify for coverage. 

According to a VA memo obtained by ProPublica, the change is based on a Jan. 1 presidential order titled “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government.” VA Press Secretary Pete Kasperowicz told ProPublica that the policy was changed because the previous policy “falsely classified male breasts as reproductive organs.” 

In 2024, the VA added male breast cancer (along with urethral cancer and cancer of the paraurethral glands) to its list of presumed service-connected disabilities due to military environmental exposure, such as toxic burn pits. Male breast cancer was added to the category of “reproductive cancer of any type” after experts pointed to the similarity of male and female breast cancers.

Establishing a connection between a variety of cancers and military service has been a years-long fight only resolved recently in the form of the 2022 PACT Act. The VA lists > 20 medical conditions as “presumptive” for service connection, with some caveats, such as area of service. The act reduced the burden of proof needed: The terms “presumptive conditions” and “presumptive-exposure locations” mean veterans only have to provide their military records to show they were in an exposure location to have their care for certain conditions covered. 

Supporters of the PACT Act say the policy change could make it harder for veterans to receive timely care, a serious issue for men with breast cancer who have been “severely underrepresented” in clinical studies and many studies specifically exclude males. The American Cancer Society estimates about 2800 men have been or will be diagnosed with invasive breast cancer in 2025. Less than 1% of breast cancers in the US occur in men, but breast cancer is notably higher among veterans: 11% of 3304 veterans, according to a 2023 study. 

Breast cancer is more aggressive in men—they’re more often diagnosed at Stage IV and tend to be older—and survival rates have been lower than in women. In a 2019 study of 16,025 male and 1,800,708 female patients with breast cancer, men had 19% higher overall mortality.

Treatment for male breast cancer has lagged. A 2021 study found men were less likely than women to receive radiation therapy. However, that’s changing. Since that study, however, the American Cancer Society claims treatments and survival rates have improved. According to the Surveillance, Epidemiology, and End Results database, 5-year survival rates are 97% for localized, 86% for regional, and 31% for distant; 84% for all stages combined.

Screening and treatment have focused on women. But the VA Breast and Gynecologic Oncology System of Excellence (BGSoE) provides cancer care for all veterans diagnosed with breast malignancies. Male veterans with breast cancer do face additional challenges in addressing a cancer that is most often associated with females. “I must admit, it was awkward every time I went [to the Women’s Health Center for postmastectomy follow-ups]” William K. Lewis, described in his patient perspective on male breast cancer treatment in the VA.

Though the policy has changed, Kasperowicz told ProPublica that veterans who previously qualified for coverage can keep it: “The department grants disability benefits compensation claims for male Veterans with breast cancer on an individual basis and will continue to do so. VA encourages any male Veterans with breast cancer who feel their health may have been impacted by their military service to submit a disability compensation claim.”

Male veterans with breast cancer may have a more difficult time receiving appropriate health care due to a recently revised US Department of Veterans Affairs (VA) policy that requires each individual to prove the disease’s connection to their service to qualify for coverage. 

According to a VA memo obtained by ProPublica, the change is based on a Jan. 1 presidential order titled “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government.” VA Press Secretary Pete Kasperowicz told ProPublica that the policy was changed because the previous policy “falsely classified male breasts as reproductive organs.” 

In 2024, the VA added male breast cancer (along with urethral cancer and cancer of the paraurethral glands) to its list of presumed service-connected disabilities due to military environmental exposure, such as toxic burn pits. Male breast cancer was added to the category of “reproductive cancer of any type” after experts pointed to the similarity of male and female breast cancers.

Establishing a connection between a variety of cancers and military service has been a years-long fight only resolved recently in the form of the 2022 PACT Act. The VA lists > 20 medical conditions as “presumptive” for service connection, with some caveats, such as area of service. The act reduced the burden of proof needed: The terms “presumptive conditions” and “presumptive-exposure locations” mean veterans only have to provide their military records to show they were in an exposure location to have their care for certain conditions covered. 

Supporters of the PACT Act say the policy change could make it harder for veterans to receive timely care, a serious issue for men with breast cancer who have been “severely underrepresented” in clinical studies and many studies specifically exclude males. The American Cancer Society estimates about 2800 men have been or will be diagnosed with invasive breast cancer in 2025. Less than 1% of breast cancers in the US occur in men, but breast cancer is notably higher among veterans: 11% of 3304 veterans, according to a 2023 study. 

Breast cancer is more aggressive in men—they’re more often diagnosed at Stage IV and tend to be older—and survival rates have been lower than in women. In a 2019 study of 16,025 male and 1,800,708 female patients with breast cancer, men had 19% higher overall mortality.

Treatment for male breast cancer has lagged. A 2021 study found men were less likely than women to receive radiation therapy. However, that’s changing. Since that study, however, the American Cancer Society claims treatments and survival rates have improved. According to the Surveillance, Epidemiology, and End Results database, 5-year survival rates are 97% for localized, 86% for regional, and 31% for distant; 84% for all stages combined.

Screening and treatment have focused on women. But the VA Breast and Gynecologic Oncology System of Excellence (BGSoE) provides cancer care for all veterans diagnosed with breast malignancies. Male veterans with breast cancer do face additional challenges in addressing a cancer that is most often associated with females. “I must admit, it was awkward every time I went [to the Women’s Health Center for postmastectomy follow-ups]” William K. Lewis, described in his patient perspective on male breast cancer treatment in the VA.

Though the policy has changed, Kasperowicz told ProPublica that veterans who previously qualified for coverage can keep it: “The department grants disability benefits compensation claims for male Veterans with breast cancer on an individual basis and will continue to do so. VA encourages any male Veterans with breast cancer who feel their health may have been impacted by their military service to submit a disability compensation claim.”

A new drug currently known as NG101 reduced nausea and vomiting in patients with obesity using GLP-1s by 40% and 67%, respectively, based on data from a phase 2 trial presented at the Obesity Society’s Obesity Week 2025 in Atlanta.

Previous research published in JAMA Network Open showed a nearly 65% discontinuation rate for three GLP-1s (liraglutide, semaglutide, or tirzepatide) among adults with overweight or obesity and without type 2 diabetes. Gastrointestinal (GI) side effects topped the list of reasons for dropping the medications.

Given the impact of nausea and vomiting on discontinuation, there is an unmet need for therapies to manage GI symptoms, said Kimberley Cummings, PhD, of Neurogastrx, Inc., in her presentation.

In the new study, Cummings and colleagues randomly assigned 90 adults aged 18-55 years with overweight or obesity (defined as a BMI ranging from 22.0 to 35.0) to receive a single subcutaneous dose of semaglutide (0.5 mg) plus 5 days of NG101 at 20 mg twice daily, or a placebo.

NG101 is a peripherally acting D2 antagonist designed to reduce nausea and vomiting associated with GLP-1 use, Cummings said. NG101 targets the nausea center of the brain but is peripherally restricted to prevent central nervous system side effects, she explained.

Compared with placebo, NG101 significantly reduced the incidence of nausea and vomiting by 40% and 67%, respectively. Use of NG101 also was associated with a significant reduction in the duration of nausea and vomiting; GI events lasting longer than 1 day were reported in 22% and 51% of the NG101 patients and placebo patients, respectively.

In addition, participants who received NG101 reported a 70% decrease in nausea severity from baseline.

Overall, patients in the NG101 group also reported significantly fewer adverse events than those in the placebo group (74 vs 135), suggesting an improved safety profile when semaglutide is administered in conjunction with NG101, the researchers noted. No serious adverse events related to the study drug were reported in either group.

The findings were limited by several factors including the relatively small sample size. Additional research is needed with other GLP-1 agonists in larger populations with longer follow-up periods, Cummings said. However, the results suggest that NG101 was safe and effectively improved side effects associated with GLP-1 agonists.

“We know there are receptors for GLP-1 in the area postrema (nausea center of the brain), and that NG101 works on this area to reduce nausea and vomiting, so the study findings were not unexpected,” said Jim O’Mara, president and CEO of Neurogastrx, in an interview.

The study was a single-dose study designed to show proof of concept, and future studies would involve treating patients going through the recommended titration schedule for their GLP-1s, O’Mara said. However, NG101 offers an opportunity to keep more patients on GLP-1 therapy and help them reach their long-term therapeutic goals, he said.

 

Decrease Side Effects for Weight-Loss Success

“GI side effects are often the rate-limiting step in implementing an effective medication that patients want to take but may not be able to tolerate,” said Sean Wharton, MD, PharmD, medical director of the Wharton Medical Clinic for Weight and Diabetes Management, Burlington, Ontario, Canada, in an interview. “If we can decrease side effects, these medications could improve patients’ lives,” said Wharton, who was not involved in the study.

The improvement after a single dose of NG101 in patients receiving a single dose of semaglutide was impressive and in keeping with the mechanism of the drug action, said Wharton. “I was not surprised by the result but pleased that this single dose was shown to reduce the overall incidence of nausea and vomiting, the duration of nausea, the severity of nausea as rated by the study participants compared to placebo,” he said.

Ultimately, the clinical implications for NG101 are improved patient tolerance for GLP-1s and the ability to titrate and stay on them long term, incurring greater cardiometabolic benefit, Wharton told this news organization.

The current trial was limited to GLP1-1s on the market; newer medications may have fewer side effects, Wharton noted. “In clinical practice, patients often decrease the medication or titrate slower, and this could be the comparator,” he added.

The study was funded by Neurogastrx.

Wharton disclosed serving as a consultant for Neurogastrx but not as an investigator on the current study. He also reported having disclosed research on various GLP-1 medications.

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

A new drug currently known as NG101 reduced nausea and vomiting in patients with obesity using GLP-1s by 40% and 67%, respectively, based on data from a phase 2 trial presented at the Obesity Society’s Obesity Week 2025 in Atlanta.

Previous research published in JAMA Network Open showed a nearly 65% discontinuation rate for three GLP-1s (liraglutide, semaglutide, or tirzepatide) among adults with overweight or obesity and without type 2 diabetes. Gastrointestinal (GI) side effects topped the list of reasons for dropping the medications.

Given the impact of nausea and vomiting on discontinuation, there is an unmet need for therapies to manage GI symptoms, said Kimberley Cummings, PhD, of Neurogastrx, Inc., in her presentation.

In the new study, Cummings and colleagues randomly assigned 90 adults aged 18-55 years with overweight or obesity (defined as a BMI ranging from 22.0 to 35.0) to receive a single subcutaneous dose of semaglutide (0.5 mg) plus 5 days of NG101 at 20 mg twice daily, or a placebo.

NG101 is a peripherally acting D2 antagonist designed to reduce nausea and vomiting associated with GLP-1 use, Cummings said. NG101 targets the nausea center of the brain but is peripherally restricted to prevent central nervous system side effects, she explained.

Compared with placebo, NG101 significantly reduced the incidence of nausea and vomiting by 40% and 67%, respectively. Use of NG101 also was associated with a significant reduction in the duration of nausea and vomiting; GI events lasting longer than 1 day were reported in 22% and 51% of the NG101 patients and placebo patients, respectively.

In addition, participants who received NG101 reported a 70% decrease in nausea severity from baseline.

Overall, patients in the NG101 group also reported significantly fewer adverse events than those in the placebo group (74 vs 135), suggesting an improved safety profile when semaglutide is administered in conjunction with NG101, the researchers noted. No serious adverse events related to the study drug were reported in either group.

The findings were limited by several factors including the relatively small sample size. Additional research is needed with other GLP-1 agonists in larger populations with longer follow-up periods, Cummings said. However, the results suggest that NG101 was safe and effectively improved side effects associated with GLP-1 agonists.

“We know there are receptors for GLP-1 in the area postrema (nausea center of the brain), and that NG101 works on this area to reduce nausea and vomiting, so the study findings were not unexpected,” said Jim O’Mara, president and CEO of Neurogastrx, in an interview.

The study was a single-dose study designed to show proof of concept, and future studies would involve treating patients going through the recommended titration schedule for their GLP-1s, O’Mara said. However, NG101 offers an opportunity to keep more patients on GLP-1 therapy and help them reach their long-term therapeutic goals, he said.

 

Decrease Side Effects for Weight-Loss Success

“GI side effects are often the rate-limiting step in implementing an effective medication that patients want to take but may not be able to tolerate,” said Sean Wharton, MD, PharmD, medical director of the Wharton Medical Clinic for Weight and Diabetes Management, Burlington, Ontario, Canada, in an interview. “If we can decrease side effects, these medications could improve patients’ lives,” said Wharton, who was not involved in the study.

The improvement after a single dose of NG101 in patients receiving a single dose of semaglutide was impressive and in keeping with the mechanism of the drug action, said Wharton. “I was not surprised by the result but pleased that this single dose was shown to reduce the overall incidence of nausea and vomiting, the duration of nausea, the severity of nausea as rated by the study participants compared to placebo,” he said.

Ultimately, the clinical implications for NG101 are improved patient tolerance for GLP-1s and the ability to titrate and stay on them long term, incurring greater cardiometabolic benefit, Wharton told this news organization.

The current trial was limited to GLP1-1s on the market; newer medications may have fewer side effects, Wharton noted. “In clinical practice, patients often decrease the medication or titrate slower, and this could be the comparator,” he added.

The study was funded by Neurogastrx.

Wharton disclosed serving as a consultant for Neurogastrx but not as an investigator on the current study. He also reported having disclosed research on various GLP-1 medications.

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

A new drug currently known as NG101 reduced nausea and vomiting in patients with obesity using GLP-1s by 40% and 67%, respectively, based on data from a phase 2 trial presented at the Obesity Society’s Obesity Week 2025 in Atlanta.

Previous research published in JAMA Network Open showed a nearly 65% discontinuation rate for three GLP-1s (liraglutide, semaglutide, or tirzepatide) among adults with overweight or obesity and without type 2 diabetes. Gastrointestinal (GI) side effects topped the list of reasons for dropping the medications.

Given the impact of nausea and vomiting on discontinuation, there is an unmet need for therapies to manage GI symptoms, said Kimberley Cummings, PhD, of Neurogastrx, Inc., in her presentation.

In the new study, Cummings and colleagues randomly assigned 90 adults aged 18-55 years with overweight or obesity (defined as a BMI ranging from 22.0 to 35.0) to receive a single subcutaneous dose of semaglutide (0.5 mg) plus 5 days of NG101 at 20 mg twice daily, or a placebo.

NG101 is a peripherally acting D2 antagonist designed to reduce nausea and vomiting associated with GLP-1 use, Cummings said. NG101 targets the nausea center of the brain but is peripherally restricted to prevent central nervous system side effects, she explained.

Compared with placebo, NG101 significantly reduced the incidence of nausea and vomiting by 40% and 67%, respectively. Use of NG101 also was associated with a significant reduction in the duration of nausea and vomiting; GI events lasting longer than 1 day were reported in 22% and 51% of the NG101 patients and placebo patients, respectively.

In addition, participants who received NG101 reported a 70% decrease in nausea severity from baseline.

Overall, patients in the NG101 group also reported significantly fewer adverse events than those in the placebo group (74 vs 135), suggesting an improved safety profile when semaglutide is administered in conjunction with NG101, the researchers noted. No serious adverse events related to the study drug were reported in either group.

The findings were limited by several factors including the relatively small sample size. Additional research is needed with other GLP-1 agonists in larger populations with longer follow-up periods, Cummings said. However, the results suggest that NG101 was safe and effectively improved side effects associated with GLP-1 agonists.

“We know there are receptors for GLP-1 in the area postrema (nausea center of the brain), and that NG101 works on this area to reduce nausea and vomiting, so the study findings were not unexpected,” said Jim O’Mara, president and CEO of Neurogastrx, in an interview.

The study was a single-dose study designed to show proof of concept, and future studies would involve treating patients going through the recommended titration schedule for their GLP-1s, O’Mara said. However, NG101 offers an opportunity to keep more patients on GLP-1 therapy and help them reach their long-term therapeutic goals, he said.

 

Decrease Side Effects for Weight-Loss Success

“GI side effects are often the rate-limiting step in implementing an effective medication that patients want to take but may not be able to tolerate,” said Sean Wharton, MD, PharmD, medical director of the Wharton Medical Clinic for Weight and Diabetes Management, Burlington, Ontario, Canada, in an interview. “If we can decrease side effects, these medications could improve patients’ lives,” said Wharton, who was not involved in the study.

The improvement after a single dose of NG101 in patients receiving a single dose of semaglutide was impressive and in keeping with the mechanism of the drug action, said Wharton. “I was not surprised by the result but pleased that this single dose was shown to reduce the overall incidence of nausea and vomiting, the duration of nausea, the severity of nausea as rated by the study participants compared to placebo,” he said.

Ultimately, the clinical implications for NG101 are improved patient tolerance for GLP-1s and the ability to titrate and stay on them long term, incurring greater cardiometabolic benefit, Wharton told this news organization.

The current trial was limited to GLP1-1s on the market; newer medications may have fewer side effects, Wharton noted. “In clinical practice, patients often decrease the medication or titrate slower, and this could be the comparator,” he added.

The study was funded by Neurogastrx.

Wharton disclosed serving as a consultant for Neurogastrx but not as an investigator on the current study. He also reported having disclosed research on various GLP-1 medications.

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

A global analysis challenged the notion that a rise in cancer is disproportionately affecting younger adults, finding instead that several cancer types previously seen rising in younger adults are also increasing in older adults.

More specifically, the analysis found that incidence rates for thyroid cancer, breast cancer, kidney cancer, endometrial cancer, and leukemia increased similarly in both younger and older adults in most countries over a 15-year period. Colorectal cancer (CRC) was the exception, where incidence rates increased in younger adults in most countries but only increased slightly in older adults in about half and decreased in about one quarter.

“Our findings suggest that whatever is triggering the rise in these cancers is more likely to be common across all age groups, rather than specific to cancers in the under 50s, since there were similar increases in younger and older adults,” Amy Berrington de González, DPhil, The Institute of Cancer Research, London, England, who led the study, said in a statement.

The authors of an editorial agreed, adding that the growing “concern about increasing cancer rates should recognize that this increase is not restricted to young adults but affects all generations.”

The study and editorial were published recently in Annals of Internal Medicine.

 

Data Defy Early-Onset Cancer Epidemic Narrative

A growing body of evidence suggests that cancer incidence rates are increasing among younger adults in many countries. However, studies tracking international trends have largely evaluated cancer incidence in younger adults without comparing these trends in older adults or analyses have focused the age comparison in individual countries, Berrington de González and colleagues explained.

To better understand cancer incidence trends across countries and age groups, the researchers evaluated cancer trends in 42 countries between 2003 and 2017, focusing on 13 cancer types previously reported to be climbing in adults younger than age 50 years.

The researchers found that incidence rates for six of the 13 cancer types increased among younger adults (aged 20-49 years) in more than three quarters of the countries studied.

The largest increase was in thyroid cancer (median average annual percentage change [AAPC], 3.57%), followed by kidney cancer (median AAPC, 2.21%), endometrial cancer (median AAPC, 1.66%), CRC (median AAPC, 1.45%), breast cancer (median AAPC, 0.89%), and leukemia (median AAPC, 0.78%).

But with the exception of CRC, incidence rates for these cancers increased to a similar degree in adults aged 50 years or older — with median AAPCs of 3% (vs 3.57%) for thyroid cancer, 1.65% (vs 2.21%) for kidney cancer, 1.20% (vs 1.66%) for endometrial cancer, 0.86% (vs 0.89%) for breast cancer, and 0.61% (vs 0.78%) for leukemia.

In older adults, CRC incidence rates only increased in about half the countries (median AAPC, 0.37%), and the annual percentage change was much greater in younger than older adults in nearly 70% of countries. CRC incidence rates in older individuals also decreased in nearly 25% of countries.

Why is CRC an apparent outlier?

“Bowel cancer screening not only helps detect cancer at earlier stages but also helps prevent cancer through the removal of premalignant lesions,” Berrington de González said. “This could be why bowel cancer cases seem to be rising faster in younger adults — we’re getting better at preventing them developing in older adults.”

The incidence of certain cancers also declined in younger adults. Specifically, rates of liver, oral, esophageal, and stomach cancers decreased in younger adults in more than half of countries assessed, with median AAPCs of -0.14% for liver, -0.42% for oral, -0.92% for esophageal, and -1.62% for stomach cancers.

Over half of countries also saw declining rates of stomach (median AAPC, -2.05%) and esophageal (median AAPC, -0.25%) cancers among older adults, while rates of liver and oral cancers increased in older individuals (median AAPC, 2.17% and 0.49%, respectively).

For gallbladder, pancreatic, and prostate cancers — three other cancers previously found to be increasing in younger adults — the researchers reported that incidence rates increased in younger adults in just over half of countries (median AAPCs, 3.2% for prostate cancer, 0.49% for gallbladder cancer, and 1% for pancreatic cancer). Incidence rates also often increased in older adults but to a lesser extent (median AAPCs, 0.75% for prostate cancer, -0.10% for gallbladder, and 0.96% for pancreatic cancer).

 

True Rise or Increased Scrutiny?

Why are cancer rates increasing?

“Understanding factors that contribute to the increase in incidence across the age spectrum was beyond the scope of the study,” editorialists Christopher Cann, MD, Fox Chase Cancer Center, and Efrat Dotan, MD, University of Pennsylvania Health System, both in Philadelphia, wrote.

Several studies have suggested that rising rates of obesity could help explain increasing cancer incidence, particularly in younger adults. In fact, “the cancers that we identified as increasing are all obesity-related cancers, including endometrial and kidney cancer,” Berrington de González said. However, so far, the evidence on this link remains unclear, she acknowledged.

Weighing in on the study, Gilbert Welch, MD, Brigham and Women’s Hospital, Boston, told this news organization that it’s “critically important” to distinguish between two explanations for rising cancer incidence.

There may be an increase in the true occurrence of clinically meaningful cancer, which “warrants investigation into biologic explanations, better treatment, and perhaps more testing,” Welch said.

But it may instead reflect changes in diagnostic scrutiny. “Simply put, whenever we doctors look harder for cancer, we find more,” Welch said. “And there are lots of ways to look harder: testing more people, testing people more frequently, using tests with increasing ability to detect small irregularities, and using lower diagnostic thresholds for labeling these as cancer.”

If increased incidence is the result of greater diagnostic scrutiny, searching for biologic causes is bound to be unproductive and more testing will only aggravate the problem, he explained.

Welch pointed out that the fastest rising cancer in both younger and older adults was thyroid cancer (AAPC, ≥ 3%), which is “exquisitely sensitive” to diagnostic scrutiny.

Take what happened in South Korea. Around 2000, the government of South Korea started a national screening program for breast, colon, and stomach cancers. Doctors and hospitals often added on ultrasound scans for thyroid cancer for a small additional fee.

“A decade later the rate of thyroid cancer diagnosis had increased 15-fold, turning what was once a rare cancer into the most common cancer in Korea,” Welch said. “But the death rate from thyroid cancer did not change. This was not an epidemic of disease; this was an epidemic of diagnosis.”

Welch also noted that the study authors and editorialists put the finding in perspective by explaining that, despite the rising rates of certain cancers in younger adults, cancer remains rare in these adults.

Welch highlighted that, for younger adults in the US, cancer death rates in young adults have cut in half over the last 30 years. “Cancer accounts for only 10% of deaths in young people in the US — and that number is falling,” Welch said.

The study was funded by the Institute of Cancer Research and the National Institutes of Health Intramural Research Program. Disclosures for authors and editorial writers are available with the original articles. Welch reported receiving royalties from three books including “Should I be tested for cancer?”

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

A global analysis challenged the notion that a rise in cancer is disproportionately affecting younger adults, finding instead that several cancer types previously seen rising in younger adults are also increasing in older adults.

More specifically, the analysis found that incidence rates for thyroid cancer, breast cancer, kidney cancer, endometrial cancer, and leukemia increased similarly in both younger and older adults in most countries over a 15-year period. Colorectal cancer (CRC) was the exception, where incidence rates increased in younger adults in most countries but only increased slightly in older adults in about half and decreased in about one quarter.

“Our findings suggest that whatever is triggering the rise in these cancers is more likely to be common across all age groups, rather than specific to cancers in the under 50s, since there were similar increases in younger and older adults,” Amy Berrington de González, DPhil, The Institute of Cancer Research, London, England, who led the study, said in a statement.

The authors of an editorial agreed, adding that the growing “concern about increasing cancer rates should recognize that this increase is not restricted to young adults but affects all generations.”

The study and editorial were published recently in Annals of Internal Medicine.

 

Data Defy Early-Onset Cancer Epidemic Narrative

A growing body of evidence suggests that cancer incidence rates are increasing among younger adults in many countries. However, studies tracking international trends have largely evaluated cancer incidence in younger adults without comparing these trends in older adults or analyses have focused the age comparison in individual countries, Berrington de González and colleagues explained.

To better understand cancer incidence trends across countries and age groups, the researchers evaluated cancer trends in 42 countries between 2003 and 2017, focusing on 13 cancer types previously reported to be climbing in adults younger than age 50 years.

The researchers found that incidence rates for six of the 13 cancer types increased among younger adults (aged 20-49 years) in more than three quarters of the countries studied.

The largest increase was in thyroid cancer (median average annual percentage change [AAPC], 3.57%), followed by kidney cancer (median AAPC, 2.21%), endometrial cancer (median AAPC, 1.66%), CRC (median AAPC, 1.45%), breast cancer (median AAPC, 0.89%), and leukemia (median AAPC, 0.78%).

But with the exception of CRC, incidence rates for these cancers increased to a similar degree in adults aged 50 years or older — with median AAPCs of 3% (vs 3.57%) for thyroid cancer, 1.65% (vs 2.21%) for kidney cancer, 1.20% (vs 1.66%) for endometrial cancer, 0.86% (vs 0.89%) for breast cancer, and 0.61% (vs 0.78%) for leukemia.

In older adults, CRC incidence rates only increased in about half the countries (median AAPC, 0.37%), and the annual percentage change was much greater in younger than older adults in nearly 70% of countries. CRC incidence rates in older individuals also decreased in nearly 25% of countries.

Why is CRC an apparent outlier?

“Bowel cancer screening not only helps detect cancer at earlier stages but also helps prevent cancer through the removal of premalignant lesions,” Berrington de González said. “This could be why bowel cancer cases seem to be rising faster in younger adults — we’re getting better at preventing them developing in older adults.”

The incidence of certain cancers also declined in younger adults. Specifically, rates of liver, oral, esophageal, and stomach cancers decreased in younger adults in more than half of countries assessed, with median AAPCs of -0.14% for liver, -0.42% for oral, -0.92% for esophageal, and -1.62% for stomach cancers.

Over half of countries also saw declining rates of stomach (median AAPC, -2.05%) and esophageal (median AAPC, -0.25%) cancers among older adults, while rates of liver and oral cancers increased in older individuals (median AAPC, 2.17% and 0.49%, respectively).

For gallbladder, pancreatic, and prostate cancers — three other cancers previously found to be increasing in younger adults — the researchers reported that incidence rates increased in younger adults in just over half of countries (median AAPCs, 3.2% for prostate cancer, 0.49% for gallbladder cancer, and 1% for pancreatic cancer). Incidence rates also often increased in older adults but to a lesser extent (median AAPCs, 0.75% for prostate cancer, -0.10% for gallbladder, and 0.96% for pancreatic cancer).

 

True Rise or Increased Scrutiny?

Why are cancer rates increasing?

“Understanding factors that contribute to the increase in incidence across the age spectrum was beyond the scope of the study,” editorialists Christopher Cann, MD, Fox Chase Cancer Center, and Efrat Dotan, MD, University of Pennsylvania Health System, both in Philadelphia, wrote.

Several studies have suggested that rising rates of obesity could help explain increasing cancer incidence, particularly in younger adults. In fact, “the cancers that we identified as increasing are all obesity-related cancers, including endometrial and kidney cancer,” Berrington de González said. However, so far, the evidence on this link remains unclear, she acknowledged.

Weighing in on the study, Gilbert Welch, MD, Brigham and Women’s Hospital, Boston, told this news organization that it’s “critically important” to distinguish between two explanations for rising cancer incidence.

There may be an increase in the true occurrence of clinically meaningful cancer, which “warrants investigation into biologic explanations, better treatment, and perhaps more testing,” Welch said.

But it may instead reflect changes in diagnostic scrutiny. “Simply put, whenever we doctors look harder for cancer, we find more,” Welch said. “And there are lots of ways to look harder: testing more people, testing people more frequently, using tests with increasing ability to detect small irregularities, and using lower diagnostic thresholds for labeling these as cancer.”

If increased incidence is the result of greater diagnostic scrutiny, searching for biologic causes is bound to be unproductive and more testing will only aggravate the problem, he explained.

Welch pointed out that the fastest rising cancer in both younger and older adults was thyroid cancer (AAPC, ≥ 3%), which is “exquisitely sensitive” to diagnostic scrutiny.

Take what happened in South Korea. Around 2000, the government of South Korea started a national screening program for breast, colon, and stomach cancers. Doctors and hospitals often added on ultrasound scans for thyroid cancer for a small additional fee.

“A decade later the rate of thyroid cancer diagnosis had increased 15-fold, turning what was once a rare cancer into the most common cancer in Korea,” Welch said. “But the death rate from thyroid cancer did not change. This was not an epidemic of disease; this was an epidemic of diagnosis.”

Welch also noted that the study authors and editorialists put the finding in perspective by explaining that, despite the rising rates of certain cancers in younger adults, cancer remains rare in these adults.

Welch highlighted that, for younger adults in the US, cancer death rates in young adults have cut in half over the last 30 years. “Cancer accounts for only 10% of deaths in young people in the US — and that number is falling,” Welch said.

The study was funded by the Institute of Cancer Research and the National Institutes of Health Intramural Research Program. Disclosures for authors and editorial writers are available with the original articles. Welch reported receiving royalties from three books including “Should I be tested for cancer?”

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

A global analysis challenged the notion that a rise in cancer is disproportionately affecting younger adults, finding instead that several cancer types previously seen rising in younger adults are also increasing in older adults.

More specifically, the analysis found that incidence rates for thyroid cancer, breast cancer, kidney cancer, endometrial cancer, and leukemia increased similarly in both younger and older adults in most countries over a 15-year period. Colorectal cancer (CRC) was the exception, where incidence rates increased in younger adults in most countries but only increased slightly in older adults in about half and decreased in about one quarter.

“Our findings suggest that whatever is triggering the rise in these cancers is more likely to be common across all age groups, rather than specific to cancers in the under 50s, since there were similar increases in younger and older adults,” Amy Berrington de González, DPhil, The Institute of Cancer Research, London, England, who led the study, said in a statement.

The authors of an editorial agreed, adding that the growing “concern about increasing cancer rates should recognize that this increase is not restricted to young adults but affects all generations.”

The study and editorial were published recently in Annals of Internal Medicine.

 

Data Defy Early-Onset Cancer Epidemic Narrative

A growing body of evidence suggests that cancer incidence rates are increasing among younger adults in many countries. However, studies tracking international trends have largely evaluated cancer incidence in younger adults without comparing these trends in older adults or analyses have focused the age comparison in individual countries, Berrington de González and colleagues explained.

To better understand cancer incidence trends across countries and age groups, the researchers evaluated cancer trends in 42 countries between 2003 and 2017, focusing on 13 cancer types previously reported to be climbing in adults younger than age 50 years.

The researchers found that incidence rates for six of the 13 cancer types increased among younger adults (aged 20-49 years) in more than three quarters of the countries studied.

The largest increase was in thyroid cancer (median average annual percentage change [AAPC], 3.57%), followed by kidney cancer (median AAPC, 2.21%), endometrial cancer (median AAPC, 1.66%), CRC (median AAPC, 1.45%), breast cancer (median AAPC, 0.89%), and leukemia (median AAPC, 0.78%).

But with the exception of CRC, incidence rates for these cancers increased to a similar degree in adults aged 50 years or older — with median AAPCs of 3% (vs 3.57%) for thyroid cancer, 1.65% (vs 2.21%) for kidney cancer, 1.20% (vs 1.66%) for endometrial cancer, 0.86% (vs 0.89%) for breast cancer, and 0.61% (vs 0.78%) for leukemia.

In older adults, CRC incidence rates only increased in about half the countries (median AAPC, 0.37%), and the annual percentage change was much greater in younger than older adults in nearly 70% of countries. CRC incidence rates in older individuals also decreased in nearly 25% of countries.

Why is CRC an apparent outlier?

“Bowel cancer screening not only helps detect cancer at earlier stages but also helps prevent cancer through the removal of premalignant lesions,” Berrington de González said. “This could be why bowel cancer cases seem to be rising faster in younger adults — we’re getting better at preventing them developing in older adults.”

The incidence of certain cancers also declined in younger adults. Specifically, rates of liver, oral, esophageal, and stomach cancers decreased in younger adults in more than half of countries assessed, with median AAPCs of -0.14% for liver, -0.42% for oral, -0.92% for esophageal, and -1.62% for stomach cancers.

Over half of countries also saw declining rates of stomach (median AAPC, -2.05%) and esophageal (median AAPC, -0.25%) cancers among older adults, while rates of liver and oral cancers increased in older individuals (median AAPC, 2.17% and 0.49%, respectively).

For gallbladder, pancreatic, and prostate cancers — three other cancers previously found to be increasing in younger adults — the researchers reported that incidence rates increased in younger adults in just over half of countries (median AAPCs, 3.2% for prostate cancer, 0.49% for gallbladder cancer, and 1% for pancreatic cancer). Incidence rates also often increased in older adults but to a lesser extent (median AAPCs, 0.75% for prostate cancer, -0.10% for gallbladder, and 0.96% for pancreatic cancer).

 

True Rise or Increased Scrutiny?

Why are cancer rates increasing?

“Understanding factors that contribute to the increase in incidence across the age spectrum was beyond the scope of the study,” editorialists Christopher Cann, MD, Fox Chase Cancer Center, and Efrat Dotan, MD, University of Pennsylvania Health System, both in Philadelphia, wrote.

Several studies have suggested that rising rates of obesity could help explain increasing cancer incidence, particularly in younger adults. In fact, “the cancers that we identified as increasing are all obesity-related cancers, including endometrial and kidney cancer,” Berrington de González said. However, so far, the evidence on this link remains unclear, she acknowledged.

Weighing in on the study, Gilbert Welch, MD, Brigham and Women’s Hospital, Boston, told this news organization that it’s “critically important” to distinguish between two explanations for rising cancer incidence.

There may be an increase in the true occurrence of clinically meaningful cancer, which “warrants investigation into biologic explanations, better treatment, and perhaps more testing,” Welch said.

But it may instead reflect changes in diagnostic scrutiny. “Simply put, whenever we doctors look harder for cancer, we find more,” Welch said. “And there are lots of ways to look harder: testing more people, testing people more frequently, using tests with increasing ability to detect small irregularities, and using lower diagnostic thresholds for labeling these as cancer.”

If increased incidence is the result of greater diagnostic scrutiny, searching for biologic causes is bound to be unproductive and more testing will only aggravate the problem, he explained.

Welch pointed out that the fastest rising cancer in both younger and older adults was thyroid cancer (AAPC, ≥ 3%), which is “exquisitely sensitive” to diagnostic scrutiny.

Take what happened in South Korea. Around 2000, the government of South Korea started a national screening program for breast, colon, and stomach cancers. Doctors and hospitals often added on ultrasound scans for thyroid cancer for a small additional fee.

“A decade later the rate of thyroid cancer diagnosis had increased 15-fold, turning what was once a rare cancer into the most common cancer in Korea,” Welch said. “But the death rate from thyroid cancer did not change. This was not an epidemic of disease; this was an epidemic of diagnosis.”

Welch also noted that the study authors and editorialists put the finding in perspective by explaining that, despite the rising rates of certain cancers in younger adults, cancer remains rare in these adults.

Welch highlighted that, for younger adults in the US, cancer death rates in young adults have cut in half over the last 30 years. “Cancer accounts for only 10% of deaths in young people in the US — and that number is falling,” Welch said.

The study was funded by the Institute of Cancer Research and the National Institutes of Health Intramural Research Program. Disclosures for authors and editorial writers are available with the original articles. Welch reported receiving royalties from three books including “Should I be tested for cancer?”

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

Individuals who served in Iraq or Afghanistan had significantly higher rates of new-onset respiratory diseases after deployment compared to non-deployed control peers, based on data from more than 48,000 veterans. The findings were presented at the American College of Allergy, Asthma, and Immunology (ACAAI) 2025 Annual Meeting.

“Veterans deployed to Iraq and Afghanistan were often exposed to airborne hazards such as burn pits and dust storms,” said Patrick Gleeson, MD, an allergist at the University of Pennsylvania Perelman School of Medicine, Philadelphia, in a press release. 

“We found that these exposures may have long-term health impacts, particularly for respiratory diseases that can affect quality of life for years after service,” said Gleeson, who presented the results at the meeting.

Gleeson and colleagues used data from the Veterans Affairs Corporate Data Warehouse and Observational Medical Outcomes Partnership to identify veterans with a single deployment as part of Operation Iraqi Freedom or Operation Enduring Freedom. Participants had at least one outpatient visit prior to deployment with no baseline history of asthma, chronic rhinitis, chronic rhinosinusitis, or nasal polyposis. The mean age of the participants at deployment was 26.7 years, 84% were male, 75% were White, and 11% were Hispanic or Latino. Each was matched with a similar non-deployed veteran control.

The primary outcome was outpatient diagnoses or problem list entries for asthma, chronic rhinitis, chronic rhinosinusitis, or nasal polyposis.

Compared to non-deployed peers, deployed veterans had a 55% increased risk of asthma, a 48% increased risk of nasal polyposis, a 41% increased risk of chronic rhinitis, and a 27% increased risk of chronic rhinosinusitis, based on Cox proportional hazards models (P < .0005 for all).

The findings were limited by the retrospective design. However, “Recognizing the link between deployment and respiratory disease can help guide medical support, policy, and preventive strategies for those affected,” Gleeson said in the press release. 

The study received no outside funding. The researchers disclosed no financial conflicts of interest.

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

Individuals who served in Iraq or Afghanistan had significantly higher rates of new-onset respiratory diseases after deployment compared to non-deployed control peers, based on data from more than 48,000 veterans. The findings were presented at the American College of Allergy, Asthma, and Immunology (ACAAI) 2025 Annual Meeting.

“Veterans deployed to Iraq and Afghanistan were often exposed to airborne hazards such as burn pits and dust storms,” said Patrick Gleeson, MD, an allergist at the University of Pennsylvania Perelman School of Medicine, Philadelphia, in a press release. 

“We found that these exposures may have long-term health impacts, particularly for respiratory diseases that can affect quality of life for years after service,” said Gleeson, who presented the results at the meeting.

Gleeson and colleagues used data from the Veterans Affairs Corporate Data Warehouse and Observational Medical Outcomes Partnership to identify veterans with a single deployment as part of Operation Iraqi Freedom or Operation Enduring Freedom. Participants had at least one outpatient visit prior to deployment with no baseline history of asthma, chronic rhinitis, chronic rhinosinusitis, or nasal polyposis. The mean age of the participants at deployment was 26.7 years, 84% were male, 75% were White, and 11% were Hispanic or Latino. Each was matched with a similar non-deployed veteran control.

The primary outcome was outpatient diagnoses or problem list entries for asthma, chronic rhinitis, chronic rhinosinusitis, or nasal polyposis.

Compared to non-deployed peers, deployed veterans had a 55% increased risk of asthma, a 48% increased risk of nasal polyposis, a 41% increased risk of chronic rhinitis, and a 27% increased risk of chronic rhinosinusitis, based on Cox proportional hazards models (P < .0005 for all).

The findings were limited by the retrospective design. However, “Recognizing the link between deployment and respiratory disease can help guide medical support, policy, and preventive strategies for those affected,” Gleeson said in the press release. 

The study received no outside funding. The researchers disclosed no financial conflicts of interest.

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

Individuals who served in Iraq or Afghanistan had significantly higher rates of new-onset respiratory diseases after deployment compared to non-deployed control peers, based on data from more than 48,000 veterans. The findings were presented at the American College of Allergy, Asthma, and Immunology (ACAAI) 2025 Annual Meeting.

“Veterans deployed to Iraq and Afghanistan were often exposed to airborne hazards such as burn pits and dust storms,” said Patrick Gleeson, MD, an allergist at the University of Pennsylvania Perelman School of Medicine, Philadelphia, in a press release. 

“We found that these exposures may have long-term health impacts, particularly for respiratory diseases that can affect quality of life for years after service,” said Gleeson, who presented the results at the meeting.

Gleeson and colleagues used data from the Veterans Affairs Corporate Data Warehouse and Observational Medical Outcomes Partnership to identify veterans with a single deployment as part of Operation Iraqi Freedom or Operation Enduring Freedom. Participants had at least one outpatient visit prior to deployment with no baseline history of asthma, chronic rhinitis, chronic rhinosinusitis, or nasal polyposis. The mean age of the participants at deployment was 26.7 years, 84% were male, 75% were White, and 11% were Hispanic or Latino. Each was matched with a similar non-deployed veteran control.

The primary outcome was outpatient diagnoses or problem list entries for asthma, chronic rhinitis, chronic rhinosinusitis, or nasal polyposis.

Compared to non-deployed peers, deployed veterans had a 55% increased risk of asthma, a 48% increased risk of nasal polyposis, a 41% increased risk of chronic rhinitis, and a 27% increased risk of chronic rhinosinusitis, based on Cox proportional hazards models (P < .0005 for all).

The findings were limited by the retrospective design. However, “Recognizing the link between deployment and respiratory disease can help guide medical support, policy, and preventive strategies for those affected,” Gleeson said in the press release. 

The study received no outside funding. The researchers disclosed no financial conflicts of interest.

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

TOPLINE: Large Language Models (LLMs) achieve more than 95% accuracy in extracting colorectal cancer and dysplasia diagnoses from Veterans Health Administration (VHA) pathology reports, including patients with Million Veteran Program (MVP) genomic data. The validated approach using publicly available LLMs demonstrates excellent performance across both Inflammatory Bowel Disease (IBD) and non-IBD populations.

METHODOLOGY: 

Researchers analyzed 116,373 pathology reports generated in the VHA between 1999 and 2024, utilizing search term filtering followed by simple yes/no question prompts for identifying colorectal dysplasia, high-grade dysplasia and/or colorectal adenocarcinoma, and invasive colorectal cancer.

• Results were compared to blinded manual chart review of 200 to 300 pathology reports for each patient cohort and diagnostic task, totaling 3,816 reviewed reports, to validate the LLM approach.

• Validation was performed independently in IBD and non-IBD populations using Gemma-2 and Llama-3 LLMs without any task-specific training or fine-tuning.

• Performance metrics included F1 scores, positive predictive value, negative predictive value, sensitivity, specificity, and Matthew's correlation coefficient to evaluate accuracy across different tasks.

TAKEAWAY:

• In patients with IBD in the MVP, the LLM achieved (F1-score, 96.9%; 95% confidence interval [CI], 94.0%-99.6%) for identifying dysplasia, (F1-score, 93.7%; 95% CI, 88.2%-98.4%) for identifying high-grade dysplasia/colorectal cancer, and (F1-score, 98%; 95% CI, 96.3%-99.4%) for identifying colorectal cancer.

• In non-IBD MVP patients, the LLM demonstrated (F1-score, 99.2%; 95% CI, 98.2%-100%) for identifying colorectal dysplasia, (F1-score, 96.5%; 95% CI, 93.0%-99.2%) for high-grade dysplasia/colorectal cancer, and (F1-score, 95%; 95% CI, 92.8%-97.2%) for identifying colorectal cancer.

• Agreement between reviewers was excellent across tasks, with (Cohen's kappa, 89%-97%) for main tasks, and (Cohen's kappa, 78.1%-93.1%) for indefinite for dysplasia in IBD cohort.

• The LLM approach maintained high accuracy when applied to full pathology reports, with (F1-score, 97.1%; 95% CI, 93.5%-100%) for dysplasia detection in IBD patients.

IN PRACTICE: “We have shown that LLMs are powerful, potentially generalizable tools for accurately extracting important information from clinical semistructured and unstructured text and which require little human-led development.” the authors of the study wrote

SOURCE: The study was based on data from the Million Veteran Program and supported by the Office of Research and Development, Veterans Health Administration, and the US Department of Veterans Affairs Biomedical Laboratory. It was published online in BMJ Open Gastroenterology.

LIMITATIONS:  According to the authors, this research may be specific to the VHA system and the LLM models used. The authors did not test larger models. The authors acknowledge that without long-term access to graphics processing units, they could not feasibly test larger models, which may overcome some of the shortcomings seen in smaller models. Additionally, the researchers could not rule out overlap between Million Veteran Program and Corporate Data Warehouse reports, though they state that results in either cohort alone are sufficient validation compared with previously published work.

DISCLOSURES: The study was supported by Merit Review Award from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service, AGA Research Foundation, National Institutes of Health grants, and the National Library of Medicine Training Grant. Kit Curtius reported receiving an investigator-led research grant from Phathom Pharmaceuticals. Shailja C Shah disclosed being a paid consultant for RedHill Biopharma and Phathom Pharmaceuticals, and an unpaid scientific advisory board member for Ilico Genetics, Inc.

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

TOPLINE: Large Language Models (LLMs) achieve more than 95% accuracy in extracting colorectal cancer and dysplasia diagnoses from Veterans Health Administration (VHA) pathology reports, including patients with Million Veteran Program (MVP) genomic data. The validated approach using publicly available LLMs demonstrates excellent performance across both Inflammatory Bowel Disease (IBD) and non-IBD populations.

METHODOLOGY: 

Researchers analyzed 116,373 pathology reports generated in the VHA between 1999 and 2024, utilizing search term filtering followed by simple yes/no question prompts for identifying colorectal dysplasia, high-grade dysplasia and/or colorectal adenocarcinoma, and invasive colorectal cancer.

• Results were compared to blinded manual chart review of 200 to 300 pathology reports for each patient cohort and diagnostic task, totaling 3,816 reviewed reports, to validate the LLM approach.

• Validation was performed independently in IBD and non-IBD populations using Gemma-2 and Llama-3 LLMs without any task-specific training or fine-tuning.

• Performance metrics included F1 scores, positive predictive value, negative predictive value, sensitivity, specificity, and Matthew's correlation coefficient to evaluate accuracy across different tasks.

TAKEAWAY:

• In patients with IBD in the MVP, the LLM achieved (F1-score, 96.9%; 95% confidence interval [CI], 94.0%-99.6%) for identifying dysplasia, (F1-score, 93.7%; 95% CI, 88.2%-98.4%) for identifying high-grade dysplasia/colorectal cancer, and (F1-score, 98%; 95% CI, 96.3%-99.4%) for identifying colorectal cancer.

• In non-IBD MVP patients, the LLM demonstrated (F1-score, 99.2%; 95% CI, 98.2%-100%) for identifying colorectal dysplasia, (F1-score, 96.5%; 95% CI, 93.0%-99.2%) for high-grade dysplasia/colorectal cancer, and (F1-score, 95%; 95% CI, 92.8%-97.2%) for identifying colorectal cancer.

• Agreement between reviewers was excellent across tasks, with (Cohen's kappa, 89%-97%) for main tasks, and (Cohen's kappa, 78.1%-93.1%) for indefinite for dysplasia in IBD cohort.

• The LLM approach maintained high accuracy when applied to full pathology reports, with (F1-score, 97.1%; 95% CI, 93.5%-100%) for dysplasia detection in IBD patients.

IN PRACTICE: “We have shown that LLMs are powerful, potentially generalizable tools for accurately extracting important information from clinical semistructured and unstructured text and which require little human-led development.” the authors of the study wrote

SOURCE: The study was based on data from the Million Veteran Program and supported by the Office of Research and Development, Veterans Health Administration, and the US Department of Veterans Affairs Biomedical Laboratory. It was published online in BMJ Open Gastroenterology.

LIMITATIONS:  According to the authors, this research may be specific to the VHA system and the LLM models used. The authors did not test larger models. The authors acknowledge that without long-term access to graphics processing units, they could not feasibly test larger models, which may overcome some of the shortcomings seen in smaller models. Additionally, the researchers could not rule out overlap between Million Veteran Program and Corporate Data Warehouse reports, though they state that results in either cohort alone are sufficient validation compared with previously published work.

DISCLOSURES: The study was supported by Merit Review Award from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service, AGA Research Foundation, National Institutes of Health grants, and the National Library of Medicine Training Grant. Kit Curtius reported receiving an investigator-led research grant from Phathom Pharmaceuticals. Shailja C Shah disclosed being a paid consultant for RedHill Biopharma and Phathom Pharmaceuticals, and an unpaid scientific advisory board member for Ilico Genetics, Inc.

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

TOPLINE: Large Language Models (LLMs) achieve more than 95% accuracy in extracting colorectal cancer and dysplasia diagnoses from Veterans Health Administration (VHA) pathology reports, including patients with Million Veteran Program (MVP) genomic data. The validated approach using publicly available LLMs demonstrates excellent performance across both Inflammatory Bowel Disease (IBD) and non-IBD populations.

METHODOLOGY: 

Researchers analyzed 116,373 pathology reports generated in the VHA between 1999 and 2024, utilizing search term filtering followed by simple yes/no question prompts for identifying colorectal dysplasia, high-grade dysplasia and/or colorectal adenocarcinoma, and invasive colorectal cancer.

• Results were compared to blinded manual chart review of 200 to 300 pathology reports for each patient cohort and diagnostic task, totaling 3,816 reviewed reports, to validate the LLM approach.

• Validation was performed independently in IBD and non-IBD populations using Gemma-2 and Llama-3 LLMs without any task-specific training or fine-tuning.

• Performance metrics included F1 scores, positive predictive value, negative predictive value, sensitivity, specificity, and Matthew's correlation coefficient to evaluate accuracy across different tasks.

TAKEAWAY:

• In patients with IBD in the MVP, the LLM achieved (F1-score, 96.9%; 95% confidence interval [CI], 94.0%-99.6%) for identifying dysplasia, (F1-score, 93.7%; 95% CI, 88.2%-98.4%) for identifying high-grade dysplasia/colorectal cancer, and (F1-score, 98%; 95% CI, 96.3%-99.4%) for identifying colorectal cancer.

• In non-IBD MVP patients, the LLM demonstrated (F1-score, 99.2%; 95% CI, 98.2%-100%) for identifying colorectal dysplasia, (F1-score, 96.5%; 95% CI, 93.0%-99.2%) for high-grade dysplasia/colorectal cancer, and (F1-score, 95%; 95% CI, 92.8%-97.2%) for identifying colorectal cancer.

• Agreement between reviewers was excellent across tasks, with (Cohen's kappa, 89%-97%) for main tasks, and (Cohen's kappa, 78.1%-93.1%) for indefinite for dysplasia in IBD cohort.

• The LLM approach maintained high accuracy when applied to full pathology reports, with (F1-score, 97.1%; 95% CI, 93.5%-100%) for dysplasia detection in IBD patients.

IN PRACTICE: “We have shown that LLMs are powerful, potentially generalizable tools for accurately extracting important information from clinical semistructured and unstructured text and which require little human-led development.” the authors of the study wrote

SOURCE: The study was based on data from the Million Veteran Program and supported by the Office of Research and Development, Veterans Health Administration, and the US Department of Veterans Affairs Biomedical Laboratory. It was published online in BMJ Open Gastroenterology.

LIMITATIONS:  According to the authors, this research may be specific to the VHA system and the LLM models used. The authors did not test larger models. The authors acknowledge that without long-term access to graphics processing units, they could not feasibly test larger models, which may overcome some of the shortcomings seen in smaller models. Additionally, the researchers could not rule out overlap between Million Veteran Program and Corporate Data Warehouse reports, though they state that results in either cohort alone are sufficient validation compared with previously published work.

DISCLOSURES: The study was supported by Merit Review Award from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service, AGA Research Foundation, National Institutes of Health grants, and the National Library of Medicine Training Grant. Kit Curtius reported receiving an investigator-led research grant from Phathom Pharmaceuticals. Shailja C Shah disclosed being a paid consultant for RedHill Biopharma and Phathom Pharmaceuticals, and an unpaid scientific advisory board member for Ilico Genetics, Inc.

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

Trauma-focused evidence-based psychotherapies (TF-EBPs), including cognitive processing therapy (CPT) and prolonged exposure therapy (PE), are recommended treatments for posttraumatic stress disorder (PTSD) in clinical practice guidelines.^1-3 To increase initiation of these treatments, the US Department of Veterans Affairs (VA) used a large-scale dissemination and implementation effort to improve access to TF-EBP.^4,5 These efforts achieved modest success, increasing prevalence of TF-EBP from a handful of veterans in 2004 to an annual prevalence of 14.6% for CPT and 4.3% for PE in 2014.⁶

Throughout these efforts, qualitative studies have been used to better understand veterans’ perspectives on receiving TF-EBP care.^7-18 Barriers to initiation of and engagement in TF-EBP and PTSD care have been identified from these qualitative studies. One identified barrier was lack of knowledge—particularly lack of knowledge about what is meant by a PTSD diagnosis and available treatments.^7-10 Stigma (ie, automatic negative associations) toward mental health problems or seeking mental health care also has been identified as a barrier to initiation.^7,10-14 Perceptions of poor alignment between treatment and veteran goals, including lack of buy-in for the rationale, served as barriers to initiation and engagement.^8,15-18

Using prior qualitative work, numerous initiatives have been developed to reduce stigma, facilitate conversations about how treatment aligns with goals, and fill knowledge gaps, particularly through online resources and shared decision-making.^19,20 To better inform the state of veterans’ experiences with TF-EBP, a qualitative investigation was conducted involving veterans who recently initiated TF-EBP. Themes directly related to transitions to TF-EBP were identified; however, all veterans interviewed also described their experiences with TFEBP engagement and mental health care. Consistent with recommendations for qualitative methods, this study extends prior work on transitions to TF-EBP by describing themes with a distinct focus on the experience of engaging with TF-EBP and mental health care.^21,22

Methods

The experiences of veterans who were transitioning into TF-EBPs were collected in semistructured interviews and analyzed. The semistructured interview guide was developed and refined in consultation with both qualitative methods experts and PTSD treatment experts to ensure that 6 content domains were appropriately queried: PTSD treatment options, cultural sensitivity of treatment, PTSD treatment selection, transition criteria, beliefs about stabilization treatment, and treatment needs/preferences.

Participants were identified using the VA Corporate Data Warehouse and included post-9/11 veterans who had recently initiated CPT or PE for the first time between September 1, 2021, and September 1, 2022. More details of participant selection are available in Holder et al.²¹ From a population of 10,814 patients, stratified random sampling generated a recruitment pool of 200 veterans for further outreach. The strata were defined such that this recruitment pool had similar proportions of demographic characteristics (ie, gender, race, ethnicity) to the population of eligible veterans, equivalent distributions of time to CPT or PE initiation (ie, 33.3% < 1 year, 33.3% 1-3 years, and 33.3% > 3 years), and adequate variability in TF-EBP type (ie, 66.7% CPT, 33.3% PE). A manual chart review in the recruitment pool excluded 12 veterans who did not initiate CPT or PE, 1 veteran with evidence of current active psychosis and/or cognitive impairment that would likely preclude comprehension of study materials, and 1 who was deceased.

Eligible veterans from the recruitment pool were contacted in groups of 25. First, a recruitment letter with study information and instructions to opt-out of further contact was mailed or emailed to veterans. After 2 weeks, veterans who had not responded were contacted by phone up to 3 times. Veterans interested in participating were scheduled for a 1-time visit that included verbal consent and the qualitative interview. Metrics were established a priori to ensure an adequately diverse and inclusive sample. Specifically, a minimum number of racial and/or ethnic minority veterans (33%) and women veterans (20%) were sought. Equal distribution across the 3 categories of time from first mental health visit to CPT/PE initiation also was targeted. Throughout enrollment, recruitment efforts were adapted to meet these metrics in the emerging sample. While the goal was to generate a diverse and inclusive sample using these methods, the sample was not intended to be representative of the population.

Of the 186 eligible participants, 21 declined participation and 26 could not be reached. The targeted sample was reached after exhausting contact for 47 veterans and contacting 80 veterans for a final response rate of 40% among fully contacted veterans and 27% among veterans with any contact. The final sample included 30 veterans who received CPT or PE in VA facilities (Table).

After veterans provided verbal consent for study participation, sociodemographic information was verbally reported, and a 30- to 60-minute semistructured qualitative phone interview was recorded and transcribed. Veterans received $40 for participation. All procedures were approved by the University of California San Francisco Institutional Review Board.

Qualitative Data Analysis

Rapid analysis procedures were used to analyze qualitative data. This approach is suitable for focused, moderately structured qualitative analyses in health services research and facilitates rapid dissemination to stakeholders.²³ The qualitative analysts were 2 clinical psychologists with expertise in PTSD treatment (NH primary and RR secondary). Consistent with rapid analysis procedures, analysts prepared a templated summary (including relevant quotations) of each interview, organized by the prespecified content domains. Interviews were summarized independently, compared to ensure consistency, and discrepancies were resolved through review of the interview source materials. Individual summary templates were combined into a master analytic matrix to facilitate the identification of patterns and delineation of themes. Analysts routinely met to identify, discuss, and refine preliminary themes, revisiting source materials to reach consensus as needed.

Results

Fifteen themes were identified and organized into 2 distinct focus areas: themes directly related to the transition to TF-EBP (8 themes) and themes related to veterans’ experiences with TF-EBP and general mental health care with potential process-improvement implications (7 themes).²¹ Seven themes were identified related to experiences with TF-EBP engagement and VA mental health care. The 7 themes related to TF-EBP engagement and VA mental health care themes are summarized with exemplary quotations.

Veterans want a better understanding of psychotherapy and engaging with VA mental health. Veterans reported that they generally had a poor or “nebulous” understanding about the experience of psychotherapy. For example, veterans exhibited confusion about whether certain experiences were equivalent to participating in psychotherapy. They were sometimes unable to distinguish between interactions such as assessment, disability evaluations, peer support, and psychotherapy. One veteran described a conversation with a TFEBP therapist about prior treatment:

She [asked], have you ever been, or gone through a therapy to begin with? And I, I said, well I just chatted with somebody. And she said that’s not, that’s not therapy. So, I was like, oh, it’s not? That’s not what people do?

Veterans were surprised the VA offered a diverse range of psychotherapy interventions, rather than simply therapy. They did not realize there were different types of psychotherapy. As a result, veterans were not aware that some VA mental practitioners have specialty training and certification to provide treatment matched to specific diagnoses or needs. They thought that all clinicians could provide the same care. One veteran described their understanding:

I just figured all mental health people are mental health people. I didn’t have a better understanding of the system and all the different levels and how it plays out and specialties and things like that. Which, I guess, I should have because you have a primary care doctor, but then you have specialists in all these other different sectors that specialize in one particular area. I guess that should’ve been common sense, but it wasn’t.

Stigma was a barrier to seeking and engaging in mental health care. Veterans discovered they had to overcome stigma associated with seeking and engaging in mental health treatment. Military culture was often discussed as promoting stigma regarding mental health treatment. Specifically, veterans described that seeking treatment meant “either, I’m weak or I’m gonna be seen as weak.” In active-duty settings, the strategy for dealing with mental health symptoms was to “leave those feelings, you push ‘em aside,” an approach highly inconsistent with TF-EBP. In some cases, incorrect information about the VA and PTSD was presented as part of discharge from the military, leading to long-term skepticism of the VA and PTSD treatment. One veteran described his experience as part of a class on the VA compensation and pension assessment process for service-connected disabilities during his military discharge:

[A fellow discharging soldier asked] what about like PTSD, gettin’ rated for PTSD. I hear they take our weapons and stuff like we can’t own firearms and all that stuff. And [the instructor] was like, well, yes that’s a thing. He didn’t explain it like if you get compensated for PTSD you don’t lose your rights to carry a firearm or to have, to be able to go hunting.

Importantly, veterans often described how other identities (eg, race, ethnicity, gender, region of origin) interacted with military culture to enhance stigma. Hearing messaging from multiple sources reinforced beliefs that mental health treatment is inappropriate or is associated with weakness:

As a first-generation Italian, I was always taught keep your feelings to yourself. Never talk outside your family. Never bring up problems to other people and stuff like that. Same with the military. And then the old stigma working in [emergency medical services] and public safety, you’re weak if you get help.

The fundamentals of therapy, including rapport and flexibility, were important. Veterans valued nonspecific therapy factors, genuine empathy, building trust, being honest about treatment, personality, and rapport. These characteristics were almost universally described as particularly important:

I liked the fact that she made it personable and she cared. It wasn’t just like, here, we’re gonna start this. She explained it in the ways I could understand, not in medical terms, so to speak, but that’s what I liked about her. She really cared about what she did and helping me.

Flexibility was viewed as an asset, particularly when clinicians acknowledged veteran autonomy. A consistent example was when veterans were able to titrate trauma disclosure. One veteran described this flexible treatment experience: “She was right there in the room, she said, you know, at any time, you know, we could stop, we could debrief.”

Experiences of clinician flexibility and personalization of therapy were contrasted with experiences of overly rigid therapy. Overemphasis on protocols created barriers, often because treatment did not feel personalized. One veteran described how a clinician’s task-oriented approach interfered with their ability to engage in TF-EBP:

They listened, but it just didn’t seem like they were listening, because they really wanted to stay on task… So, I felt like if the person was more concerned, or more sympathetic to the things that was also going on in my life at that present time, I think I would’ve felt more comfortable talking about what was the PTSD part, too.

Veterans valued shared decision-making prior to TF-EBP initiation. Veterans typically described being involved in a shared decision-making process prior to initiating TF-EBP. During these sessions, clinicians discussed treatment options and provided veterans with a variety of materials describing treatments (eg, pamphlets, websites, videos, statistics). Most veterans appreciated being able to reflect on and discuss treatment options with their clinicians. Being given time in and out of session to review was viewed as valuable and increased confidence in treatment choice. One veteran described their experience:

I was given the information, you know, they gave me handouts, PDFs, whatever was available, and let me read over it. I didn’t have to choose anything right then and there, you know, they let me sleep on it. And I got back to them after some thought.

However, some veterans felt overwhelmed by being presented with too much information and did not believe they knew enough to make a final treatment decision. One veteran described being asked to contribute to the treatment decision:

I definitely asked [the clinician] to weigh in on maybe what he thought was best, because—I mean, I don’t know… I’m not necessarily sure I know what I think is best. I think we’re just lucky I’m here, so if you can give me a solid and help me out here by telling me just based on what I’ve said to you and the things that I’ve gone through, what do you think?

Veterans who perceived that their treatment preferences were respected had a positive outlook on TF-EBP. As part of the shared-decision making process, veterans typically described being given choices among PTSD treatments. One way that preferences were respected was through clinicians tailoring treatment descriptions to a veteran’s unique symptoms, experiences, and values. In these cases, clinicians observed specific concerns and clearly linked treatment principles to those concerns. For example, one veteran described their clinician’s recommendation for PE: “The hardest thing for me is to do the normal things like grocery store or getting on a train or anything like that. And so, he suggested that [PE] would be a good idea.”

In other cases, veterans wanted the highest quality of treatment rather than a match between treatment principles and the veteran’s presentation, goals, or strengths. These veterans wanted the best treatment available for PTSD and valued research support, recommendations from clinical practice guidelines, or clinician confidence in the effectiveness of the treatment. One veteran described this perspective:

I just wanted to be able to really tackle it in the best way possible and in the most like aggressive way possible. And it seemed like PE really was going to, they said that it’s a difficult type of therapy, but I really just wanted to kind of do the best that I could to eradicate some of the issues that I was having.

When veterans perceived a lack of respect for their preferences, they were hesitant about TF-EBP. For some veterans, a generic pitch for a TF-EBP was detrimental in the absence of the personal connection between the treatment and their own symptoms, goals, or strengths. These veterans did not question whether the treatment was effective in general but did question whether the treatment was best for them. One veteran described the contrast between their clinician’s perspective and their own.

I felt like they felt very comfortable, very confident in [CPT] being the program, because it was comfortable for them. Because they did it several times. And maybe they had a lot of success with other individuals... but they were very comfortable with that one, as a provider, more than: Is this the best fit for [me]?

Some veterans perceived little concern for their preferences and a lack of choice in available treatments, which tended to perpetuate negative perceptions of TFEBP. These veterans described their lack of choices with frustration. Alternatives to TFEBP were described by these veterans as so undesirable that they did not believe they had a real choice:

[CPT] was the only decision they had. There was nothing else for PTSD. They didn’t offer anything else. So, I mean it wasn’t a decision. It was either … take treatment or don’t take treatment at all… Actually, I need to correct myself. So, there were 2 options, group therapy or CPT. I forgot about that. I’m not a big group guy so I chose the CPT.

Another veteran was offered a choice between therapeutic approaches, but all were delivered via telehealth (consistent with the transition to virtual services during the COVID-19 pandemic). For this veteran, not only was the distinction between approaches unclear, but the choice between approaches was unimportant compared to the mode of delivery.

This happened during COVID-19 and VA stopped seeing anybody physically, face-to-face. So my only option for therapy was [telehealth]… There was like 3 of them, and I tried to figure out, you know, from the layperson’s perspective, like: I don’t know which one to go with.

Veterans wanted to be asked about their cultural identity. Veterans valued when clinicians asked questions about cultural identity as part of their mental health treatment and listened to their cultural context. Cultural identity factors extended beyond factors such as race, ethnicity, gender, and sexual orientation to religion, military culture, and regionality. Veterans often described situations where they wished clinicians would ask the question or initiate conversations about culture. A veteran highlighted the importance of their faith but noted that it was a taboo topic. Their clinician did not say “we don’t go there,” but they “never dove into it either.” Another veteran expressed a desire for their clinician to ask questions about experiences in the National Guard and as an African American veteran:

If a provider was to say like: Oh, you know, it’s a stressful situation being a part of the military, being in the National Guard. You know, just asking questions about that. I think that would really go a long way… Being African American was difficult as well. And more so because of my region, I think… I felt like it would probably be an uncomfortable subject to speak on… I mean, it wasn’t anything that my providers necessarily did, it was more so just because it wasn’t brought up.

One common area of concern for veterans was a match between veteran and therapist demographics. When asked about how their cultural identity influenced treatment, several veterans described the relevance of therapist match. Much like questions about their own cultural identity, veterans valued being asked about identity preferences in clinicians (eg, gender or race matching), rather than having to bring up the preference themselves. One veteran described relief at this question being asked directly: “I was relieved when she had asked [whether I wanted a male or female clinician] primarily because I was going to ask that or bring that up somehow. But her asking that before me was a weight off my shoulders.”

Discussing cultural identity through treatment strengthened veterans’ engagement in therapy. Many veterans appreciated when analogies used in therapy were relevant to their cultural experiences and when clinicians understood their culture (eg, military culture, race, ethnicity, religious beliefs, sexual orientation). One veteran described how their clinician understood military culture and made connections between military culture and the rationale for TF-EBP, which strengthened the veteran’s buy-in for the treatment and alliance with the clinician:

At the beginning when she was explaining PTSD, and I remember she said that your brain needed to think this way when you were in the military because it was a way of protecting and surviving, so your brain was doing that in order for you to survive in whatever areas you were because there was danger. So, your brain had you thinking that way. But now, you’re not in those situations anymore. You’re not in danger. You’re not in the military, but your brain is still thinking you are, and that’s what PTSD generally does to you.

Specific elements of TF-EBP also provided opportunities to discuss and integrate important aspects of identity. This is accomplished in PE by assigning relevant in vivo exercises. In CPT, “connecting the dots” on how prior experiences influenced trauma-related stuck points achieved this element. One veteran described their experience with a clinician who was comfortable discussing the veteran’s sexual orientation and recognized the impacts of prior trauma on intimacy:

They’re very different, and there’s a lot of things that can be accepted in gay relationships that are not in straight ones. With all that said, I think [the PE therapist] did a fantastic job being not—like never once did she laugh or make an uncomfortable comment or say she didn’t wanna talk about something when like part of the reason I wanted to get into therapy is that my partner and I weren’t having sex unless I used alcohol.

Discussion

As part of a larger national qualitative investigation of the experiences of veterans who recently initiated TF-EBP, veterans discussed their experiences with therapy and mental health care that have important implications for continued process improvement.²¹ Three key areas for continued process improvement were identified: (1) providing information about the diverse range of mental health care services at the VA and the implications of this continuum of care; (2) consideration of veteran preferences in treatment decision-making, including the importance of perceived choice; and (3) incorporating cultural assessment and cultural responsiveness into case conceptualization and treatment.

One area of process improvement identified was increasing knowledge about different types of psychotherapy and the continuum of care available at the VA. Veterans in this study confused or conflated participating in psychotherapy with talking about mental health symptoms with a clinician (eg, assessment, disability evaluation). They were sometimes surprised that psychotherapy is an umbrella term referring to a variety of different modalities. The downstream impact of these misunderstandings was a perception of VA mental health care as nebulous. Veterans were surprised that all mental health practitioners were unable to provide the same care. Confusion may have been compounded by highly variable referral processes across VA.²⁴ To address this, clinicians have developed local educational resources and handouts for both veterans and referring clinicians from nonmental health and general mental health specialties.²⁵ Given the variability in referral processes both between and within VA medical centers, national dissemination of these educational materials may be more difficult compared to materials for TF-EBPs.²⁴ The VA started to use behavioral health interdisciplinary program (BHIP) teams, which are designed to be clinical homes for veterans connected with a central clinician who can explain and coordinate their mental health care as well as bring more consistency to the referral process.²⁶ The ongoing transition toward the BHIP model of mental health care at VA may provide the opportunity to consolidate and integrate knowledge about the VA approach to mental health care, potentially filling knowledge gaps.

A second area of process improvement focused on the shared decision-making process. Consistent with mental health initiatives, veterans generally believed they had received sufficient information about TF-EBP and engaged in shared decision-making with clinicians.^20,27 Veterans were given educational materials to review and had the opportunity to discuss these materials with clinicians. However, veterans described variability in the success of shared decision-making. Although veterans valued receiving accurate, comprehensible information to support treatment decisions, some preferred to defer to clinicians’ expertise regarding which treatment to pursue. While these veterans valued information, they also valued the expertise of clinicians in explaining why specific treatments would be beneficial. A key contributor to veterans satisfaction was assessing how veterans wanted to engage in the decision-making process and respecting those preferences.²⁸ Veterans approached shared decision-making differently, from making decisions independently after receiving information to relying solely on clinician recommendation. The process was most successful when clinicians articulated how their recommended treatment aligned with a veteran’s preferences, including recommendations based on specific values (eg, personalized match vs being the best). Another important consideration is ensuring veterans know they can receive a variety of different types of mental health services available in different modalities (eg, virtual vs in-person; group vs individual). When veterans did not perceive choice in treatment aspects important to them (typically despite having choices), they were less satisfied with their TF-EBP experience.

A final area of process improvement identified involves how therapists address important aspects of culture. Veterans often described mental health stigma coming from intersecting cultural identities and expressed appreciation when therapists helped them recognize the impact of these beliefs on treatment. Some veterans did not discuss important aspects of their identity with clinicians, including race/ethnicity, religion, and military culture. Veterans did not report negative interactions with clinicians or experiences suggesting it was inappropriate to discuss identity; however, they were reluctant to independently raise these identity factors. Strategies such as the ADDRESSING framework, a mnemonic acronym that describes a series of potentially relevant characteristics, can help clinicians comprehensively consider different aspects that may be relevant to veterans, modeling that discussion of relevant these characteristics is welcome in TF-EBP.²⁹ Veterans reported that making culturally relevant connections enhanced the TF-EBP experience, most commonly with military culture. These data support that TF-EBP delivery with attention to culture should be an integrated part of treatment, supporting engagement and therapeutic alliance.³⁰ The VA National Center for PTSD consultation program is a resource to support clinicians in assessing and incorporating relevant aspects of cultural identity.³¹ For example, the National Center for PTSD provides a guide for using case conceptualization to address patient reactions to race-based violence during PTSD treatment.³² Both manualized design and therapist certification training can reinforce that assessing and attending to case conceptualization (including identity factors) is an integral component of TF-EBP.^33,34

Limitations

While the current study has numerous strengths (eg, national veteran sampling, robust qualitative methods), results should be considered within the context of study limitations. First, veteran participants all received TF-EBP, and the perspectives of veterans who never initiate TF-EBP may differ. Despite the strong sampling approach, the study design is not intended to be generalizable to all veterans receiving TF-EBP for PTSD. Qualitative analysis yielded 15 themes, described in this study and prior research, consistent with recommendations.^21,22 This approach allows rich description of distinct focus areas that would not be possible in a single manuscript. Nonetheless, all veterans interviewed described their experiences in TF-EBP and general mental health care, the focus of the semistructured interview guide was on the experience of transitioning from other treatment to TF-EBP.

Conclusion

This study describes themes related to general mental health and TF-EBP process improvement as part of a larger study on transitions in PTSD care.^21,22 Veterans valued the fundamentals of therapy, including rapport and flexibility. Treatment-specific rapport (eg, pointing out treatment progress and effort in completing treatment components) and flexibility within the context of fidelity (ie, personalizing treatment while maintaining core treatment elements) may be most effective at engaging veterans in recommended PTSD treatments.^18,34 In addition to successes, themes suggest multiple opportunities for process improvement. Ongoing VA initiatives and priorities (ie, BHIP, shared decision-making, consultation services) aim to improve processes consistent with veteran recommendations. Future research is needed to evaluate the success of these and other programs to optimize access to and engagement in recommended PTSD treatments.