Cancer incidence in the US military: An updated analysis.

BACKGROUND: Military and general populations differ in factors related to cancer occurrence and diagnosis. This study compared incidence of colorectal, lung, prostate, testicular, breast, and cervical cancers between the US military and general US populations. METHODS: Data from the US Department of Defense's Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program were analyzed. Persons in ACTUR were active-duty members 20-59 years old during 1990-013. The same criteria applied to persons in SEER. Age-adjusted incidence rates, incidence rate ratios, and 95% confidence intervals were calculated by sex, race, age, and cancer stage. Temporal trends were analyzed. RESULTS: ACTUR had higher rates of prostate and breast cancers, particularly in 40- to 59-year-olds. Further analyses by tumor stage showed this was primarily confined to localized stage. Incidence rates of colorectal, lung, testicular, and cervical cancers were significantly lower in ACTUR than in SEER, primarily for regional and distant tumors in men. Temporal incidence trends were generally similar overall and by stage between the populations, although distant colorectal cancer incidence tended to decrease starting in 2006 in ACTUR whereas it increased during the same period in SEER. CONCLUSION: Higher rates of breast and prostate cancers in servicemembers 40-59 years of age than in the general population may result from greater cancer screening utilization or cumulative military exposures. Lower incidence of other cancers in servicemembers may be associated with better health status.

Survival among lung cancer patients: comparison of the U.S. military health system and the surveillance, epidemiology, and end results (SEER) program by health insurance status.

PURPOSE: The U.S. military health system (MHS) provides beneficiaries with universal health care while health care access varies in the U.S. general population by insurance status/type. We divided the patients from the U.S. general population by insurance status/type and compared them to the MHS patients in survival. METHODS: The MHS patients were identified from the Department of Defense's Automated Central Tumor Registry (ACTUR). Patients from the U.S. general population were identified from the Surveillance, Epidemiology, and End Results (SEER) program. Multivariable Cox regression analysis was conducted to compare different insurance status/type in SEER to ACTUR in overall survival. RESULTS: Compared to ACTUR patients with non-small cell lung cancer (NSCLC), SEER patients showed significant worse survival. The adjusted hazard ratios (HRs) were 1.08 [95% Confidence Interval (CI) = 1.03-1.13], 1.22 (95% CI = 1.16-1.28), 1.40 (95% CI = 1.33-1.47), 1.50 (95% CI = 1.41-1.59), for insured, insured/no specifics, Medicaid, and uninsured patients, respectively. The pattern was consistently observed in subgroup analysis by race, gender, age, or tumor stage. Results were similar for small cell lung cancer (SCLC), although they were only borderline significant in some subgroups. CONCLUSION: The survival advantage of patients receiving care from a universal health care system over the patients from the general population was not restricted to uninsured or Medicaid as expected, but was present cross all insurance types, including patients with private insurance. Our findings highlight the survival benefits of universal health care system to lung cancer patients.

Five-year survival of patients with late-stage prostate cancer: comparison of the Military Health System and the U.S. general population.

BACKGROUND: While the 5-year survival rate for local and regional prostate cancer is nearly 100%, it decreases dramatically for advanced tumours. Accessibility to health care is an important factor for cancer prognosis. The U.S. Military Health System (MHS) provides universal health care to its beneficiaries, reducing financial barriers to medical care. However, whether the universal care translates into improved survival among patients with advanced prostate cancer in the MHS is unknown. In this study, we compared the MHS and the U.S. general population in survival of patients with advanced prostate cancer (stages III and IV). METHODS: The MHS patients (N = 5379) were identified from the Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR). Patients in the U.S. general population (N = 21,516) were identified from the Surveillance, Epidemiology, and End Results (SEER) programme. The two populations were matched on age, race, and diagnosis year. RESULTS: The ACTUR patients exhibited longer 5-year survival than the matched SEER patients (HR = 0.74, 95% CI = 0.67-0.83), after adjustment for the potential confounders. The improved survival was observed for ages 50 years or older, both White patients and Black patients, all tumour stages and grades. This was also demonstrated despite the receipt of surgery or radiation treatment. CONCLUSIONS: MHS beneficiaries with advanced prostate cancer had longer survival than their counterparts in the U.S. general population.

The relationship between prior psychiatric diagnosis and brain cancer diagnosis in the U.S. military health system.

PURPOSE: Prior research suggested the increased likelihood of brain cancer diagnosis following certain psychiatric diagnoses. This association may result from detection bias or suggest an early sign for brain cancer. This study investigated whether psychiatric illness may be an early manifestation of brain cancer while considering potential effects of detection bias. METHODS: This case-control study used the data from the Department of Defense's Central Cancer Registry and the Military Health System Data Repository. Four cancer-free controls and one negative-outcome control (cancers not associated with psychiatric illness) were matched to each brain cancer case diagnosed from 1998 to 2013 by age, sex, race, and military status. The groups were compared in the likelihood of having a pre-existing psychiatric diagnosis using conditional logistic regression. RESULTS: We found a significant association of psychiatric illnesses with brain cancer (Odds Ratio (OR) = 2.63, 95% confidence interval (CI) = 2.18-3.16) and other cancers (OR = 1.80, 95% CI = 1.49-2.19), compared to non-cancer controls. The association was stronger for psychiatric diagnoses within three months before cancer (brain cancer: OR = 26.77, 95% CI = 15.40-46.53; other cancers: OR = 4.12, 95% CI = 1.96-8.65). The association with psychiatric disorders within 3 months were higher for small brain tumors (OR = 128.32, 95% CI = 17.28-952.92 compared to non-cancer controls) while the OR was 2.79 for other cancers (95% CI = 0.86-8.99 compared to non-cancer controls). CONCLUSION: Our findings suggest an association between diagnosed psychiatric illnesses and subsequent brain cancer diagnosis, which may not be solely explained by detection bias. Psychiatric illness might be a sign for early detection of brain cancer beyond the potential effects of detection bias.

Dual use of cigarettes and smokeless tobacco among active duty service members in the US military.

The high prevalence of dual use of cigarettes and smokeless tobacco is a unique tobacco use behavior in the US military population. However, dual tobacco use has rarely been addressed in active duty populations. We aimed to identify factors contributing to dual tobacco use among active duty service members from Army and Air Force. We also compared age at initiation, duration of use, and amount of use between dual users and exclusive users. The study included 168 exclusive cigarette smokers, 171 exclusive smokeless tobacco users, and 110 dual users. In stepwise logistic regression, smokeless tobacco use among family members (OR = 4.78, 95% CI = 2.05-11.13 for father use vs. no use, OR = 3.39, 95% CI = 1.56-7.37 for other relatives use vs. no use), and deployment history (serving combat unit vs. combat support unit: OR = 4.12, 95% CI = 1.59-10.66; never deployed vs. combat support unit: OR = 3.32, 95% CI = 1.45-7.61) were factors identified to be associated with dual use relative to exclusive cigarette smoking. Cigarette smoking among family members (OR = 1.96, 95% CI = 1.07-3.60 for sibling smoking), high perception of harm using smokeless tobacco (OR = 2.34, 95% CI = 1.29-4.26), secondhand smoke exposure (OR = 4.83, 95% CI = 2.73-8.55), and lower education (associated degree or some college: OR = 2.76, 95% CI = 1.01-7.51; high school of lower: OR = 4.10, 95% CI = 1.45-11.61) were factors associated with dual use relative to exclusive smokeless tobacco use. Compared to exclusive cigarette smokers, dual users started smoking at younger age, smoked cigarettes for longer period, and smoked more cigarettes per day. Our study addressed dual tobacco use behavior in military population and has implications to tobacco control programs in the military.

Racial disparities in survival among women with endometrial cancer in an equal access system.

OBJECTIVE: The mortality rate for Black women with endometrial cancer (EC) is double that of White women, although the incidence rate is lower among Black women. Unequal access to care may contribute to this racial disparity. This study aimed to assess whether survival varied between non-Hispanic Black (NHB) and non-Hispanic White (NHW) women with EC in the Military Health System (MHS) which provides equal access care to its beneficiaries despite racial/ethnic background. METHODS: The study was conducted using data from the U.S. Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR). Study subjects included NHB and NHW women with histologically confirmed and surgically managed EC diagnosed between 1988 and 2013. The study outcome was all-cause death. Overall survival between NHB and NHW women was compared using multivariable Cox modeling. RESULTS: The study included 144 NHB and 1439 NHW women with EC. Kaplan-Meier curves showed NHB women had worse survival than NHW women (log-rank P < 0.0001). The disparity in survival between NHB and NHW women persisted after adjusting for age, diagnosis period, tumor stage, tumor histology/grade, and adjuvant treatment (HR = 1.64, 95% CI = 1.19 to 2.27). Multivariable analyses stratified by tumor features or treatment showed that the racial disparity was confined to women with low-risk features (stage I/II disease or low-grade EC) or no adjuvant treatment. CONCLUSION: There were racial differences in overall survival between NHB and NHW women with EC in the MHS equal access healthcare system, suggesting that factors other than access to care may be related to this racial disparity.

Tumour size and overall survival among surgically treated patients with non-metastatic colon cancer in the U.S. Military Health System.

AIM: Larger tumour size and lymph node involvement traditionally predict poorer survival in colon cancer patients. However, it has been recently suggested that very small tumours (<5 mm) may be a predictor of poor prognosis in colon cancer patients when lymph nodes are involved. This study investigated whether node-positive colon cancer patients with small tumours had worse survival compared to those with larger tumours in the Department of Defense's (DoD) Military Health System (MHS), a universal health care system. METHODS: Surgically treated colon cancer patients were identified from the DoD's Automated Central Tumour Registry (ACTUR). These patients were diagnosed with Stage I-III colon cancer between 1989 and 2010, had one or more lymph nodes examined, did not receive pre-operative radiotherapy and were followed through 2013 to determine vital status. Multivariable Cox models were used to examine survival differences according to tumour size, and data were stratified by lymph node status and age. RESULTS: There were no differences in overall survival according to tumour size in the study population. These findings remained similar in analyses stratified by lymph node status and age. CONCLUSION: In a universal healthcare system, small tumour size is not associated with worse prognosis in node-positive colon cancer patients.

Survival in Pediatric, Adolescent, and Young Adult Patients With Sarcoma in the Military Health System: Comparison With the SEER Population.

BACKGROUND: We sought to compare survival outcomes of sarcomas in the pediatric and adolescent/young adult populations with universal care access in the Military Health System (MHS) to those from the United States general population. METHODS: We compared data from the Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program on the overall survival of patients 24 years or younger with histologically or microscopically confirmed sarcoma between diagnosed between January 1, 1987, and December 31, 2013. The Kaplan-Meier survival curves were used to compare survival between the 2 patient populations. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) comparing ACTUR relative to SEER. RESULTS: The final analysis included 309 and 1236 bone sarcoma cases and 465 and 1860 soft tissue sarcoma cases from ACTUR and SEER, respectively. Cox proportional hazards analysis showed soft tissue sarcoma patients in ACTUR had significantly better overall (HR=0.73, 95% CI=0.55-0.98) and 5-year overall (HR=0.63, 95% CI=0.46-0.86) survival compared with SEER patients, but no significant difference in overall or 5-year overall survival between ACTUR and SEER patients with bone sarcoma. CONCLUSION: Survival data from the ACTUR database demonstrated significantly improved overall survival for soft tissue sarcomas and equivalent survival in bone sarcomas compared with that reported by SEER.

Survival among patients with glioma in the US Military Health System: A comparison with patients in the Surveillance, Epidemiology, and End Results program.

BACKGROUND: Glioma is the most common malignant brain cancer. Accessibility to health care is an important factor affecting cancer outcomes in the US general population. The US Military Health System (MHS) provides universal health care to its beneficiaries. It is unknown whether this universal health care has translated into improved survival outcomes among MHS beneficiaries with glioma. This study compared the overall survival of patients with glioma in the MHS with the overall survival of patients with glioma in the general population. METHODS: The MHS cases were identified from the Department of Defense's Automated Central Tumor Registry (ACTUR). Glioma cases from the general population were identified from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. SEER cases were matched 2:1 to ACTUR cases by age, sex, race, histology, and diagnosis year. All cases had histologically confirmed glioma diagnosed between January 1, 1987, and December 31, 2013. A Kaplan-Meier analysis was conducted to compare survival between the ACTUR and SEER cases. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: The study included 2231 glioma cases from ACTUR and 4462 cases from SEER. ACTUR cases exhibited significantly better overall survival than SEER cases (HR, 0.74; 95% CI, 0.67-0.83). The survival advantage of the ACTUR patients was observed in most subgroups stratified by age, sex, race, diagnosis year, and histology. For glioblastoma, the survival advantage was observed in both the pre- and post-temozolomide periods. CONCLUSIONS: Universal MHS health care may have translated into improved survival outcomes in glioma. Future studies are warranted to identify factors contributing to the improved survival.

Comorbidity and stage at diagnosis among lung cancer patients in the US military health system.

PURPOSE: We investigated the association between comorbidities and stage at diagnosis among NSCLC patients in the US Military Health System (MHS), which provides universal health care to its beneficiaries. METHODS: The linked data from the Department of Defense's Central Cancer Registry (CCR) and the MHS Data Repository (MDR) were used. The study included 4768 patients with histologically confirmed primary NSCLC. Comorbid conditions were extracted from the MDR data. Comorbid conditions were those included in the Charlson Comorbidity Index (CCI) and were defined as a diagnosis during a 3-year time frame prior to the NSCLC diagnosis. Multivariable logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) of late stage (stages III and IV) versus early stage (stages I and II) in relation to pre-existing comorbidities. RESULTS: Compared to patients with no comorbidities, those with prior comorbidities tended to be less likely to have lung cancer diagnosed at late stage. When specific comorbidities were analyzed, decreased odds of being diagnosed at late stage were observed among those with chronic obstructive pulmonary disease (COPD) (adjusted OR 0.78, 95% CI 0.68 to 0.90). In contrast, patients with a congestive heart failure or a liver cirrhosis/chronic hepatitis had an increased likelihood of being diagnosed at late stage (adjusted OR 1.30, 95% CI 1.00 to 1.69 and adjusted OR 1.87, 95% CI 1.24 to 2.82, respectively). CONCLUSIONS: Among NSCLC patients in an equal access health system, the likelihood of late stage at diagnosis differed by specific comorbid diseases.

Age and Lymph Node Positivity in Patients With Colon and Rectal Cancer in the US Military Health System.

BACKGROUND: Young age may be associated with an increased risk of lymph node involvement at diagnosis of colorectal cancer. Accessibility to care, which is related to cancer detection, tumor stage, and therefore lymph node positivity, may vary by age and thus influence research results. OBJECTIVE: The purpose of this study was to investigate whether young patients had an increased risk of lymph node-positive colon and rectal cancers in the Department of Defense Military Health System, which provides universal health care to its beneficiaries. DESIGN: This was a retrospective, cross-sectional study. SETTINGS: Patients were identified from the US Department of Defense Automated Central Tumor Registry. PATIENTS: Included patients were diagnosed with histologically confirmed primary stage I to III colon and rectal adenocarcinomas between 1989 and 2013, had surgery and ≥1 lymph node examined, and did not receive preoperative radiotherapy. Logistic regression was used to examine the relationships between age at diagnosis (18-49, 50-59, 60-69, and ≥70 y) and lymph node positivity overall and stratified by tumor T stage and number of lymph nodes examined. MAIN OUTCOME MEASURES: Lymph node positivity of colon and rectal cancers was measured. RESULTS: The youngest patients (aged 18-49 y) were more likely to have lymph node-positive colon and rectal cancers compared with those who were aged ≥70 years after adjustment for potential confounders (OR = 2.04 and 95% CI, 1.63-2.56 for colon cancer; OR = 1.73 and 95% CI, 1.11-2.70 for rectal cancer). A similar tendency was shown in most colon and rectal cancer subgroups stratified by tumor T stage and number of lymph nodes examined. LIMITATIONS: This study was limited by its small sample size for certain subgroup analyses. No information on comorbidities, BMI, or other indicators of health status was available. CONCLUSIONS: In a universal healthcare system, young age was associated with increased lymph node positivity of colon and rectal cancers, suggesting that factors other than access to care may play a role in this association. See Video Abstract at http://links.lww.com/DCR/B90. EDAD Y POSITIVIDAD DE GANGLIOS LINFÁTICOS EN PACIENTES CON CÁNCER DEL COLON Y EL RECTO EN EL SISTEMA DE SALUD MILITAR DE EE UU: La edad temprana puede estar asociada con un mayor riesgo de compromiso de los ganglios linfáticos en el momento del diagnóstico de cáncer colorrectal. La accesibilidad a la atención medica, que está relacionada con la detección del cáncer, el estadio del tumor y, por lo tanto, la positividad de los ganglios linfáticos, puede variar según la edad y, por lo tanto, influir en los resultados de la investigación.Investigar si los pacientes jóvenes tenían un mayor riesgo de cáncer del colon y el recto con ganglios linfáticos positivos en el Sistema de Salud Militar del Departamento de Defensa, que brinda atención médica universal a sus beneficiarios.Estudio transversal retrospectivo.Se identificaron pacientes del Registro Automático Central de Tumores del Departamento de Defensa de los Estados Unidos.Fueron diagnosticados con adenocarcinomas del colon y el recto en estadio I-III confirmados histológicamente entre 1989-2013, se les realizó una cirugía y se examinaron ≥ 1 ganglio linfático, y no recibieron radioterapia preoperatoria. La regresión logística se utilizó para examinar las relaciones entre la edad al momento del diagnóstico (18-49, 50-59, 60-69 y ≥70 años) y la positividad de los ganglios linfáticos en general y fue estratificada por el estadio T tumoral y el número de ganglios linfáticos examinados.Positividad de ganglios linfáticos de cáncer del colon y el recto.Los pacientes más jóvenes (18-49 años) tenían más probabilidades de tener cáncer del colon y el recto con ganglios linfáticos positivos en comparación con aquellos que tenían 70 años o más después del ajuste por posibles factores de confusión (odds ratio: 2.04, intervalo de confianza del 95%: 1.63 -2.56 para el cáncer de colon; odds ratio: 1.73, intervalo de confianza del 95%: 1.11-2.70 para el cáncer de recto). Se mostró una tendencia similar en la mayoría de los subgrupos de cáncer del colon y el recto estratificados por el estadio T tumoral y el número de ganglios linfáticos examinados.Tamaño de muestra pequeño para ciertos análisis de subgrupos. No hay información sobre comorbilidades, índice de masa corporal u otros indicadores del estado de salud.En un sistema de salud universal, la edad joven se asoció con un aumento de la positividad de los ganglios linfáticos del cáncer del colon y el recto, lo que sugiere que otros factores además del acceso a la atención medica pueden desempeñar un papel en esta asociación. Consulte Video Resumen en http://links.lww.com/DCR/B90.

Factors related to re-excision procedures following primary breast-conserving surgery for women with breast cancer in the U.S. Military Health System.

BACKGROUND AND OBJECTIVES: Re-excision surgery is undertaken to obtain clear margins after breast-conserving surgery (BCS) for localized breast cancer. This study examines patient and tumor characteristics related to re-excision surgery in the universal-access Military Health System (MHS). METHODS: Retrospective analysis of patients with pathologically confirmed stage I-III breast cancer between 1998 and 2014 in the Department of Defense Central Cancer Registry and MHS Data Repository-linked databases who received primary BCS. Multivariable stepwise logistic regression methods identified characteristics associated with re-excision surgery (lumpectomy and mastectomy) and conversion to mastectomy, given as adjusted odds ratios (AOR) and 95% confidence intervals (CIs). RESULTS: Of 7637 women receiving BCS, 26.3% had a re-excision and 9.9% converted to mastectomy. Tumor location, larger tumor size (≥4 cm), and regional lymph node involvement were associated with a greater likelihood of re-excision and mastectomy conversion. Pathology before BCS (AOR, 0.39; 95% CI, 0.35, 0.44 for re-excision) and neoadjuvant treatment (AOR, 0.50; 95% CI, 0.36, 0.69 for re-excision) were associated with a decreased likelihood of these outcomes. Additionally, age, tumor histology, and military-specific variables were associated with mastectomy conversion. CONCLUSION: Comprehensive preoperative workup, including tumor pathology, may better inform surgical decision-making and reduce re-excision rates.

Time-to-surgery and overall survival after breast cancer diagnosis in a universal health system.

PURPOSE: It is unclear whether time between breast cancer diagnosis and surgery is associated with survival and whether this relationship is affected by access to care. We evaluated the association between time-to-surgery and overall survival among women in the universal-access U.S. Military Health System (MHS). METHODS: Women aged 18-79 who received surgical treatment for stages I-III breast cancer between 1998 and 2010 were identified in linked cancer registry and administrative databases with follow-up through 2015. Multivariable Cox regression models were used to estimate risk of all-cause death associated with time-to-surgery intervals. RESULTS: The study included 9669 women with 93.1% survival during the study period. The hazards ratios (95% confidence intervals) of all-cause death associated with time-to-surgery were 1.15 (0.93, 1.42) for 0 days, 1.00 (reference) for 1-21 days, 0.97 (0.78, 1.21) for 22-35 days, and 1.30 (1.04, 1.61) for ≥ 36 days. The higher risk of mortality associated with time-to-surgery ≥ 36 days tended to be consistent when analyzed by surgery type, age at diagnosis, and tumor stage. CONCLUSIONS: In the MHS, longer time-to-surgery for breast cancer was associated with poorer overall survival, suggesting the importance of timeliness in receiving surgical treatment for breast cancer in relation to overall survival.

Racial differences in brain cancer characteristics and survival: an analysis of SEER data.

PURPOSE: Racial disparity with shorter survival for Blacks than Whites is well known for many cancers. However, for brain cancer, some national cancer registry studies have shown better survival among Blacks compared to Whites. This study aimed to systematically investigate whether Blacks and Whites differ in survival and also in tumor characteristics and treatment for neuroepithelial brain tumors. METHODS: The National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database was used to identify non-Hispanic White and Black patients diagnosed with malignant, histologically confirmed neuroepithelial brain cancer from 2004 through 2015. Racial differences in brain cancer survival were compared using Kaplan-Meier curve and Cox proportional hazard models. The associations of race with tumor and treatment characteristics (location, size, grade, surgical type) were examined using multinomial logistic regression. RESULTS: After adjusting for demographic, tumor, and treatment factors, there were no significant differences in survival for non-Hispanic Blacks compared to non-Hispanic Whites [hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.99-1.10]. Non-Hispanic Blacks had higher odds of being diagnosed with tumors of unknown grade [odds ratio (OR) 1.16, 95% CI 1.05-1.29], unknown size (OR 1.14, 95% CI 1.01-1.29), infratentorial (OR 1.12, 95% CI 1.01-1.24) or overlapping area (OR 1.39, 95% CI 1.14-1.70), and lower odds of having a total surgical resection (OR 0.83, 95% CI 0.74-0.93). CONCLUSION: Non-Hispanic Blacks do not exhibit longer brain cancer-specific survival than non-Hispanic Whites. They were more likely to have tumors of unknown size or grade and less likely to receive total surgical resection, which may result from racial differences in access to and use of healthcare.

Race and overall survival in men diagnosed with prostate cancer in the Department of Defense Military Health System, 1990-2010.

BACKGROUND: In the U.S. general population, black men experience poorer survival after prostate cancer (CaP) diagnosis compared to white men, and findings may be impacted by unequal access to healthcare. The objective of the study is to investigate racial differences in overall survival (OS) among Department of Defense beneficiaries diagnosed with CaP. METHODS: A retrospective cohort study was conducted utilizing the Automated Central Tumor Registry within the Military Healthcare System, a system designed to provide equal access. Men diagnosed with primary prostate adenocarcinomas between 1990 and 2010 [n = 18,484; 24% Non-Hispanic black (NHB), 76% Non-Hispanic white (NHW)] were followed through 2013 for vital status. Unadjusted Kaplan-Meier estimation curves and multivariable Cox proportional hazards (PH) regression models were used to examine racial differences in OS. RESULTS: Age-specific Kaplan-Meier analyses showed equivalent OS for NHW and NHB men in all age groups, except for 75+, where NHB had poorer OS (p = 0.0048). Multivariable Cox PH models revealed no significant differences in OS for race (HR 1.02; 95% CI 0.95-1.08), except in men aged ≥ 75 years, where NHB men had poorer OS (HR 1.27; 95% CI 1.08-1.49). CONCLUSIONS: Findings suggest that in a healthcare system designed for equal access, disparities in OS among men diagnosed with CaP may not exist.

Analysis of breast cancer in young women in the Department of Defense (DOD) database.

PURPOSE: Breast tumors from young women under the age of 40 account for approximately 7% of cases and have a poor prognosis independent of established prognostic factors. We evaluated the patient population served by the Military Health System, where a disproportionate number of breast cancer cases in young women are seen and treated in a single universal coverage healthcare system. METHODS: The Military Health System Repository and the DoD Central Registration databases were used to identify female breast cancer patients diagnosed or treated at military treatment facilities from 1998 to 2007. RESULTS: 10,066 women were diagnosed with invasive breast cancer at DoD facilities from 1998 to 2007, of which 11.3% (1139), 23.4% (2355) and 65.2% (6572) were < 40, 40-49 and > 50 years old (yo), respectively, at diagnosis. 53% in the < 40 yo cohort were white, 25% were African American (AA) and 8% were Hispanic, with 14% undisclosed. Breast cancer in women diagnosed < 40 yo was more high grade (p < 0.0001), Stage II (p < 0.0001) and ER negative (p < 0.0001). There was a higher rate of bilateral mastectomies among the women < 40 compared to those 40-49 and > 50 (18.4% vs. 9.1% and 5.0%, respectively). Independent of disease stage, chemotherapy was given more frequently to < 40 yo (90.43%) and 40-49 yo (81.44%) than ≥ 50 yo (53.71%). The 10-year overall survival of younger women was similar to the ≥ 50 yo cohort. Outcomes in the African American and Hispanic subpopulations were comparable to the overall cohort. CONCLUSION: Younger women had a similar overall survival rate to older women despite receiving more aggressive treatment.

Metformin use and survival after non-small cell lung cancer: A cohort study in the US Military health system.

Research suggests that metformin may be associated with improved survival in cancer patients with type II diabetes. This study assessed whether metformin use after non-small cell lung cancer (NSCLC) diagnosis is associated with overall survival among type II diabetic patients with NSCLC in the U.S. military health system (MHS). The study included 636 diabetic patients with histologically confirmed NSCLC diagnosed between 2002 and 2007, identified from the linked database from the Department of Defense's Central Cancer Registry (CCR) and the Military Health System Data Repository (MDR). Time-dependent multivariate Cox proportional hazards models were used to assess the association between metformin use and overall survival during follow-up. Among the 636 patients, 411 died during the follow-up. The median follow-up time was 14.6 months. Increased post-diagnosis cumulative use (per 1 year of use) conferred a significant reduction in mortality (adjusted hazard ratio (HR) = 0.76; 95% CI = 0.65-0.88). Further analysis by duration of use revealed that compared to non-users, the lowest risk reduction occurred among patients with the longest duration of use (i.e. use for more than 2 years) (HR = 0.19; 95% CI = 0.09-0.40). Finally, the reduced mortality was particularly observed only among patients who also used metformin before lung cancer diagnosis and among patients at early stage of diagnosis. Prolonged duration of metformin use in the study population was associated with improved survival, especially among early stage patients. Future research with a larger number of patients is warranted.

Survival among Black and White patients with renal cell carcinoma in an equal-access health care system.

PURPOSE: Unequal access to health care may be a reason for shorter survival among Black patients with renal cell carcinoma (RCC) than among their White counterparts. No studies have investigated survival disparity among RCC patients in an equal-access health care delivery system. This study aimed to examine racial differences in survival among clear cell RCC patients in the Department of Defense's (DoD) Military Health System (MHS), which provides equal access to care to all persons. METHODS: The study used the DoD's Automated Central Tumor Registry to identify 2056 White patients and 370 Black patients diagnosed with clear cell RCC between 1988 and 2004. The subjects were followed through 2007 with a median follow-up time of 4.8 years. Kaplan-Meier survival curves were compared and a Cox model was used to estimate the hazard ratios (HRs) associated with survival by race. RESULTS: During follow-up, 1,027 White and 158 Black patients died. The Kaplan-Meier curves showed that Black patients had more favorable overall survival than did White patients (log rank p = 0.031). After adjustment for demographic, tumor, and treatment variables, the Cox model showed no statistically significant racial difference overall (adjusted HR 1.07, 95 % CI 0.90-1.28) or stratified by age, sex or tumor stage. However, among patients who did not undergo surgery, Black patients had poorer survival than White patients. CONCLUSIONS: The lack of racial difference in survival among RCC patients in the MHS may be related to equal access to health care. Improved access could reduce the survival disparity among RCC patients in the general population.

Colon cancer lymph node evaluation among military health system beneficiaries: an analysis by race/ethnicity.

BACKGROUND: The number of lymph nodes examined during colon cancer surgery falls below nationally recommended guidelines in the general population, with Blacks and Hispanics less likely to have adequate nodal evaluation in comparison to Whites. The Department of Defense's (DoD) Military Health System (MHS) provides equal access to medical care for its beneficiaries, regardless of racial/ethnic background. This study aimed to investigate whether racial/ethnic treatment differences exist in the MHS, an equal-access medical care system. METHODS: Linked data from the DoD cancer registry and administrative claims databases were used and included 2,155 colon cancer cases. Multivariate logistic regression assessed the association between race/ethnicity and the number of lymph nodes examined (<12 and ≥12) overall and for stratified analyses. RESULTS: No overall racial/ethnic differences in the number of lymph nodes examined was identified. Further stratified analyses yielded similar results, except potential racial/ethnic differences were found among persons with poorly differentiated tumors, where non-Hispanic Blacks tended to be less likely to have ≥12 lymph nodes dissected (odds ratio 0.34; 95 % confidence interval 0.14-0.80; p = 0.01) compared with non-Hispanic Whites. CONCLUSION: Racial/ethnic disparities in the number of lymph nodes evaluated among patients with colon cancer were not apparent in an equal-access healthcare system. However, among poorly differentiated tumors there might be racial/ethnic differences in nodal yield, suggesting the possible effects of factors other than access to healthcare.

Breast reconstruction after mastectomy among Department of Defense beneficiaries by race.

BACKGROUND: Postmastectomy breast reconstruction increased approximately 20% between 1998 and 2008 in the United States and has been found to improve body image, self-esteem, and quality of life. These procedures, however, tend to be less common among minority women, which may be due to variations in health care access. The Department of Defense provides equal health care access, thereby affording an exceptional environment in which to assess whether racial variations persist when access to care is equal. METHODS: Linked Department of Defense cancer registry and medical claims data were used. The receipt of reconstruction was compared between white women (n = 2974) and black women (n = 708) who underwent mastectomies to treat incident histologically confirmed breast cancer diagnosed from 1998 through 2007. RESULTS: During the study period, postmastectomy reconstruction increased among both black (27.3% to 40.0%) and white (21.8% to 40.6%) female patients with breast cancer. Receipt of reconstruction did not vary significantly by race (odds ratio, 0.93; 95% confidence interval, 0.76-1.15). Reconstruction decreased significantly with increasing age, tumor stage, and receipt of radiotherapy and was significantly more common in more recent years and among active service women, TRICARE Prime (health maintenance organization) beneficiaries, and women whose sponsor was an officer. CONCLUSIONS: The receipt of breast reconstruction did not vary by race within this equal-access health system, indicating that the racial disparities reported in previous studies may have been due in part to variations in access to health care. Additional research to determine why a large percentage of patients with breast cancer do not undergo reconstruction might be beneficial, particularly because these procedures have been associated with noncosmetic benefits.