Federal Practitioner

For there was never yet philosopher that could endure the toothache patiently

Much Ado About Nothing by William Shakespeare

Almost anyone who has worked for a long time in a US Department of Veterans Affairs (VA) clinic or hospital has had patients in dire need of dental services who could neither access nor pay for them. I have seen dental problems ranging from older veterans who were nearly edentulous and needed expensive dentures or implants to younger veterans who never had regular dental care and needed a periodontist to save their teeth, to individuals with terrible toothaches that antibiotics could not cure. As Shakespeare quips in Much Ado About Nothing, almost nothing is worse than a toothache.

Many VA primary care practitioners and social workers kept lists of local sliding-scale dentists or arranged for veterans to visit dental and hygiene school clinics for reduced fees. Even when VA dentists were not permitted to see a veteran, many would assist in finding them affordable care in the community. However, that was never enough to meet the oral health needs of veterans. One of the most common complaints of patients who otherwise were pleased with their VA health care was that it did not cover dental services.¹

Most veterans qualify for health care and other VA benefits. Dental care is an exception, with only about a quarter (26%) of the > 9 million veterans active in the Veterans Health Administration (VHA) eligible for care. Even under this restricted eligibility, about 888,000 veterans have received dental services either through the VHA or in the community. In 2025, the VA paid community-based dentists for > 3.5 million procedures for veterans, which underscores the magnitude of the demand.²

Given the gap in dental care, many veterans and their caregivers both personal and professional will likely be encouraged that in February the VA announced plans to improve access to dental care through expanding community care dental services. “Dental health is a critical component of overall well-being,” VA Secretary Doug Collins noted. VA issued a request for proposals (RFP) for a new dental administrator who would oversee the operations of a new network of dental practitioners. The new vendor contract would operationalize general dental services, like tooth extractions, as well as specialized services such as periodontics, dentures, and pharmacy support for dental medications. Most importantly, the new program would cover preventive care to help avoid many of the dental problems veterans now experience. Proposals are due March 16.²

Yet, there is a catch. The community care program will only be available to eligible veterans just like previous dental services both in the VA and the community. I was always somewhat ashamed that despite my working decades at the VHA, I never had a satisfactory answer for veterans who asked me why they were not eligible for dental care. The regulatory response is that eligibility for dental services is a complex determination depending on service-connected military service, and specialized clinical indices. Dental coverage is provided for veterans who have 100% service-connected or total disability, prisoners of war, and veterans whose dental disease exacerbates a comorbid medical condition. Those not eligible for VA dental coverage may still get treatment if they, for example, have a cancer diagnosis and without dental work the chemotherapy treatment would place them at a higher risk of an oral infection. Veterans participating in a rehabilitation program who have poor dentition that prevents them from reaching their rehabilitative goals also may receive VA dental care. In addition, some veterans who are experiencing homelessness and others who did not receive a dental examination prior to discharge from active duty may be eligible for dental benefits.³ VA also offers lower-priced dental insurance for ineligible veterans.⁴

The new RFP does little to expand eligibility of veterans to receive VA dental care, and it is hard to not see the announcement as another step in the privatization of VHA. Medically and ethically, it seems to perpetuate a double standard between physical and oral health that makes no scientific sense.^5-7 I sometimes joke that in medical school we had maybe 2 days of teaching about teeth and even that limited exposure to dental pathology was sufficient for us to learn that chronic conditions like respiratory disease and lifestyle choices like poor diet cause and contribute to dental problems.

Like so many areas of veteran care, dental health in veterans is worse compared with those who never served, making it harder to justify the exclusion of dental services from veteran health benefits. A study in Military Medicine looked at 11,539 former service members and found a higher prevalence of individuals with tooth decay, missing teeth, tooth fillings, caries, and periodontitis. While military service per se was not associated with the findings, higher rates of hypertension, hyperlipidemia, depression, and diabetes in veterans compared with nonveterans, which are related to serving in uniform, were covariates.⁸

That depression is an indirect factor in dental disease may seem surprising. However, this is more evidence that human health is truly holistic, with mutual interactions between the body (including the teeth) and mind. Oral care needs to be incorporated into the VA whole health approach for all veterans. In a series of articles in Psychiatric News, VA psychiatrist Antoinette Shappell and VA dentist Pierre Cartier identify several links between dental and mental health.^9,10 Veterans with anxiety disorders may fear going to the dentist even when care is needed. Serious mental illness may result in poor diet, and difficulty performing preventive care. Many psychotropic medications may cause xerostomia that worsens tooth decay and veterans with posttraumatic stress disorder may suffer from bruxism. I regularly saw these conditions when I worked in a primary care psychiatry clinic. Being able to coordinate with VA dentists and staff to provide integrated care would have benefited these already burdened veterans.

An estimated $5.4 billion has been spent on 3.6 million veterans who were seen in emergency departments for dental problems. That cost alone should convince policy makers that the deficit in VA dental care needs to be filled with efficacious high-quality comprehensive dental services for as many veterans as possible. And there are signs that is exactly what is happening in Congress. A bill in the House of Representatives proposes to expand dental care benefits to all veterans eligible for other VA health benefits.¹¹ There are also other legislative initiatives in the works.⁴ Together with the VA’s plans for a new community care dental network, that does give veterans and federal practitioners something to smile about.

For there was never yet philosopher that could endure the toothache patiently

Much Ado About Nothing by William Shakespeare

Almost anyone who has worked for a long time in a US Department of Veterans Affairs (VA) clinic or hospital has had patients in dire need of dental services who could neither access nor pay for them. I have seen dental problems ranging from older veterans who were nearly edentulous and needed expensive dentures or implants to younger veterans who never had regular dental care and needed a periodontist to save their teeth, to individuals with terrible toothaches that antibiotics could not cure. As Shakespeare quips in Much Ado About Nothing, almost nothing is worse than a toothache.

Many VA primary care practitioners and social workers kept lists of local sliding-scale dentists or arranged for veterans to visit dental and hygiene school clinics for reduced fees. Even when VA dentists were not permitted to see a veteran, many would assist in finding them affordable care in the community. However, that was never enough to meet the oral health needs of veterans. One of the most common complaints of patients who otherwise were pleased with their VA health care was that it did not cover dental services.¹

Most veterans qualify for health care and other VA benefits. Dental care is an exception, with only about a quarter (26%) of the > 9 million veterans active in the Veterans Health Administration (VHA) eligible for care. Even under this restricted eligibility, about 888,000 veterans have received dental services either through the VHA or in the community. In 2025, the VA paid community-based dentists for > 3.5 million procedures for veterans, which underscores the magnitude of the demand.²

Given the gap in dental care, many veterans and their caregivers both personal and professional will likely be encouraged that in February the VA announced plans to improve access to dental care through expanding community care dental services. “Dental health is a critical component of overall well-being,” VA Secretary Doug Collins noted. VA issued a request for proposals (RFP) for a new dental administrator who would oversee the operations of a new network of dental practitioners. The new vendor contract would operationalize general dental services, like tooth extractions, as well as specialized services such as periodontics, dentures, and pharmacy support for dental medications. Most importantly, the new program would cover preventive care to help avoid many of the dental problems veterans now experience. Proposals are due March 16.²

Yet, there is a catch. The community care program will only be available to eligible veterans just like previous dental services both in the VA and the community. I was always somewhat ashamed that despite my working decades at the VHA, I never had a satisfactory answer for veterans who asked me why they were not eligible for dental care. The regulatory response is that eligibility for dental services is a complex determination depending on service-connected military service, and specialized clinical indices. Dental coverage is provided for veterans who have 100% service-connected or total disability, prisoners of war, and veterans whose dental disease exacerbates a comorbid medical condition. Those not eligible for VA dental coverage may still get treatment if they, for example, have a cancer diagnosis and without dental work the chemotherapy treatment would place them at a higher risk of an oral infection. Veterans participating in a rehabilitation program who have poor dentition that prevents them from reaching their rehabilitative goals also may receive VA dental care. In addition, some veterans who are experiencing homelessness and others who did not receive a dental examination prior to discharge from active duty may be eligible for dental benefits.³ VA also offers lower-priced dental insurance for ineligible veterans.⁴

The new RFP does little to expand eligibility of veterans to receive VA dental care, and it is hard to not see the announcement as another step in the privatization of VHA. Medically and ethically, it seems to perpetuate a double standard between physical and oral health that makes no scientific sense.^5-7 I sometimes joke that in medical school we had maybe 2 days of teaching about teeth and even that limited exposure to dental pathology was sufficient for us to learn that chronic conditions like respiratory disease and lifestyle choices like poor diet cause and contribute to dental problems.

Like so many areas of veteran care, dental health in veterans is worse compared with those who never served, making it harder to justify the exclusion of dental services from veteran health benefits. A study in Military Medicine looked at 11,539 former service members and found a higher prevalence of individuals with tooth decay, missing teeth, tooth fillings, caries, and periodontitis. While military service per se was not associated with the findings, higher rates of hypertension, hyperlipidemia, depression, and diabetes in veterans compared with nonveterans, which are related to serving in uniform, were covariates.⁸

That depression is an indirect factor in dental disease may seem surprising. However, this is more evidence that human health is truly holistic, with mutual interactions between the body (including the teeth) and mind. Oral care needs to be incorporated into the VA whole health approach for all veterans. In a series of articles in Psychiatric News, VA psychiatrist Antoinette Shappell and VA dentist Pierre Cartier identify several links between dental and mental health.^9,10 Veterans with anxiety disorders may fear going to the dentist even when care is needed. Serious mental illness may result in poor diet, and difficulty performing preventive care. Many psychotropic medications may cause xerostomia that worsens tooth decay and veterans with posttraumatic stress disorder may suffer from bruxism. I regularly saw these conditions when I worked in a primary care psychiatry clinic. Being able to coordinate with VA dentists and staff to provide integrated care would have benefited these already burdened veterans.

An estimated $5.4 billion has been spent on 3.6 million veterans who were seen in emergency departments for dental problems. That cost alone should convince policy makers that the deficit in VA dental care needs to be filled with efficacious high-quality comprehensive dental services for as many veterans as possible. And there are signs that is exactly what is happening in Congress. A bill in the House of Representatives proposes to expand dental care benefits to all veterans eligible for other VA health benefits.¹¹ There are also other legislative initiatives in the works.⁴ Together with the VA’s plans for a new community care dental network, that does give veterans and federal practitioners something to smile about.

For there was never yet philosopher that could endure the toothache patiently

Much Ado About Nothing by William Shakespeare

Almost anyone who has worked for a long time in a US Department of Veterans Affairs (VA) clinic or hospital has had patients in dire need of dental services who could neither access nor pay for them. I have seen dental problems ranging from older veterans who were nearly edentulous and needed expensive dentures or implants to younger veterans who never had regular dental care and needed a periodontist to save their teeth, to individuals with terrible toothaches that antibiotics could not cure. As Shakespeare quips in Much Ado About Nothing, almost nothing is worse than a toothache.

Many VA primary care practitioners and social workers kept lists of local sliding-scale dentists or arranged for veterans to visit dental and hygiene school clinics for reduced fees. Even when VA dentists were not permitted to see a veteran, many would assist in finding them affordable care in the community. However, that was never enough to meet the oral health needs of veterans. One of the most common complaints of patients who otherwise were pleased with their VA health care was that it did not cover dental services.¹

Most veterans qualify for health care and other VA benefits. Dental care is an exception, with only about a quarter (26%) of the > 9 million veterans active in the Veterans Health Administration (VHA) eligible for care. Even under this restricted eligibility, about 888,000 veterans have received dental services either through the VHA or in the community. In 2025, the VA paid community-based dentists for > 3.5 million procedures for veterans, which underscores the magnitude of the demand.²

Given the gap in dental care, many veterans and their caregivers both personal and professional will likely be encouraged that in February the VA announced plans to improve access to dental care through expanding community care dental services. “Dental health is a critical component of overall well-being,” VA Secretary Doug Collins noted. VA issued a request for proposals (RFP) for a new dental administrator who would oversee the operations of a new network of dental practitioners. The new vendor contract would operationalize general dental services, like tooth extractions, as well as specialized services such as periodontics, dentures, and pharmacy support for dental medications. Most importantly, the new program would cover preventive care to help avoid many of the dental problems veterans now experience. Proposals are due March 16.²

Yet, there is a catch. The community care program will only be available to eligible veterans just like previous dental services both in the VA and the community. I was always somewhat ashamed that despite my working decades at the VHA, I never had a satisfactory answer for veterans who asked me why they were not eligible for dental care. The regulatory response is that eligibility for dental services is a complex determination depending on service-connected military service, and specialized clinical indices. Dental coverage is provided for veterans who have 100% service-connected or total disability, prisoners of war, and veterans whose dental disease exacerbates a comorbid medical condition. Those not eligible for VA dental coverage may still get treatment if they, for example, have a cancer diagnosis and without dental work the chemotherapy treatment would place them at a higher risk of an oral infection. Veterans participating in a rehabilitation program who have poor dentition that prevents them from reaching their rehabilitative goals also may receive VA dental care. In addition, some veterans who are experiencing homelessness and others who did not receive a dental examination prior to discharge from active duty may be eligible for dental benefits.³ VA also offers lower-priced dental insurance for ineligible veterans.⁴

The new RFP does little to expand eligibility of veterans to receive VA dental care, and it is hard to not see the announcement as another step in the privatization of VHA. Medically and ethically, it seems to perpetuate a double standard between physical and oral health that makes no scientific sense.^5-7 I sometimes joke that in medical school we had maybe 2 days of teaching about teeth and even that limited exposure to dental pathology was sufficient for us to learn that chronic conditions like respiratory disease and lifestyle choices like poor diet cause and contribute to dental problems.

Like so many areas of veteran care, dental health in veterans is worse compared with those who never served, making it harder to justify the exclusion of dental services from veteran health benefits. A study in Military Medicine looked at 11,539 former service members and found a higher prevalence of individuals with tooth decay, missing teeth, tooth fillings, caries, and periodontitis. While military service per se was not associated with the findings, higher rates of hypertension, hyperlipidemia, depression, and diabetes in veterans compared with nonveterans, which are related to serving in uniform, were covariates.⁸

That depression is an indirect factor in dental disease may seem surprising. However, this is more evidence that human health is truly holistic, with mutual interactions between the body (including the teeth) and mind. Oral care needs to be incorporated into the VA whole health approach for all veterans. In a series of articles in Psychiatric News, VA psychiatrist Antoinette Shappell and VA dentist Pierre Cartier identify several links between dental and mental health.^9,10 Veterans with anxiety disorders may fear going to the dentist even when care is needed. Serious mental illness may result in poor diet, and difficulty performing preventive care. Many psychotropic medications may cause xerostomia that worsens tooth decay and veterans with posttraumatic stress disorder may suffer from bruxism. I regularly saw these conditions when I worked in a primary care psychiatry clinic. Being able to coordinate with VA dentists and staff to provide integrated care would have benefited these already burdened veterans.

An estimated $5.4 billion has been spent on 3.6 million veterans who were seen in emergency departments for dental problems. That cost alone should convince policy makers that the deficit in VA dental care needs to be filled with efficacious high-quality comprehensive dental services for as many veterans as possible. And there are signs that is exactly what is happening in Congress. A bill in the House of Representatives proposes to expand dental care benefits to all veterans eligible for other VA health benefits.¹¹ There are also other legislative initiatives in the works.⁴ Together with the VA’s plans for a new community care dental network, that does give veterans and federal practitioners something to smile about.

Roughly 8.6% of the 17.4 million US veterans live in poverty. About 11.1% are considered food insecure (ie, unable to acquire adequate food for ≥1 household members), with another 5.3% considered very food insecure (ie, eating patterns of ≥1 household members were disrupted and their food intake was reduced at least some time during the year). Compared with nonveterans, veterans are 7.4% more likely to be food insecure.¹ This high prevalence of food insecurity and poverty has a negative impact on veteran diets.

Veterans’ diets contained more added sugars and solid fats and scored lower compared with nonveterans when assessed for diet quality with the Healthy Eating Index.² Veterans have a higher prevalence of diet-related chronic disease, including diabetes, hypertension, and obesity compared with the nonveterans.^3-5 Given the critical role of diet in health and disease risk, enhancing diet quality among veterans has garnered significant attention and calls to action.^2,6,7 While there are many factors that contribute to diet, any veteran can receive a consultation or self-refer to receive nutrition counseling effective for improving diet quality, within the US Department of Veterans Affairs (VA).

The NOVA food classification system describes diet quality by categorizing food items by processing methods and ingredients into 4 food groups.⁸ The first is unprocessed and minimally processed items (MPFs) such as fresh fruits, vegetables, and meats. MPFs consist of whole foods which can also be minimally processed (eg, chopping, drying, grinding, heating, chilling). Culinary processed foods (CPFs) are processed foods for cooking (eg, salt, butter, and vinegar) and are typically eaten in small quantities along with MPFs. Processed foods (PRFs) include canned and smoked foods, while ultra-processed foods (UPFs) are distinguished by industrial ingredients, requiring specialized tools and processing techniques, and hyper-palatability related to color, flavor, and packaging.⁸ Examples of UPFs include mass-produced breads found at grocery stores, prepackaged snacks and meals, and hydrogenated oils. UPF consumption is associated with higher risk for negative cardiometabolic outcomes, common mental disorders, and all-cause mortality.⁹ To date, only a study by Powell et al has used the NOVA classification system in a veteran population, and it was limited to a comparison of the price of UPFs and veteran body mass index (BMI).¹⁰ Therefore, it remains unknown what percentage of total energy intake (TEI) comes from UPFs in the diets of veterans.

This study sought to quantify the proportion of TEI from UPFs among a sample of patients from the VA Phoenix Health Care System (VAPHCS). Results from a 2021 global meta-analysis reveal that the US and United Kingdom have the highest intakes of UPFs in the world.¹¹ Specifically, within the US, 15 studies with 234,890 participants reveal that the majority of TEI (about 55%) comes from UPFs.¹¹ We hypothesized that this veteran sample would have a higher proportion of TEI from UPFs, possibly due to a higher prevalence of poverty and food insecurity among veterans compared with nonveterans.¹ If the percentage of TEI coming from UPF is higher or even similar to nonveterans, further efforts to increase veterans’ use of the available nutritional services would be warranted to minimize nutrition-related disease among veterans.

Methods

This is a cross-sectional, secondary data analysis of baseline 3-day food records collected from 2017 to 2020 from 92 patients recruited at VAPHCS to participate in a whole-food plant-based diet study.¹² The original study was reviewed and approved by the VAPHCS Institutional Review Board (1593830). Recruitment methods included clinician recommendation, a recorded advertisement played while phone calls were on hold, and flyers distributed throughout VAPHCS. Patients were included if they were aged 18 to 90 years, had a BMI 25.1 to 39.9, had a diagnosis of nutrition-related chronic disease (hypertension, diabetes, or hyperlipidemia), an interest and desire to make a lifestyle change, active telephone contact information (either landline or cell phone), no contraindication to be on a whole-food plant-based diet, access to transportation and a functioning kitchen, ability to prepare meals independently, access to a computer or tablet with internet access, and a digital camera or smartphone. Exclusion criteria included significant unplanned weight loss within 6 months, uncontrolled insulin-dependent diabetes with a current hemoglobin A_1c > 9%, pregnancy/lactation, taking prescribed weight loss medication, currently following a diet (eg, plant-based diet, vegan, or medical weight loss program diet), celiac disease diagnosed within 6 months, end-stage hepatic disease or renal disease requiring dialysis, active cancer or receiving chemotherapy or radiation therapy, active alcohol or substance use disorder, history of eating disorders, fasting triglyceride level > 350 mg/dL, any psychological issues that prevent adherence, inability to speak English, limited mobility, and homeless or in housing with limited kitchen access. A baseline 3-day food record was collected from the participants and used in this secondary analysis.

Diet Analysis

Food records were analyzed using Esha Research Food Processor 4.0 to identify calorie and macronutrient information. To limit bias, food items were coded independently by 2 researchers into 4 food processing groups determined by the NOVA classification: MPF, CPF, PRF, and UPF.⁸ When possible, specific ingredient information was collected using internet searches for brand product websites. Initial coding had an 89% agreement rate for food item coding between the 2 researchers. As coding was done in duplicate, a third researcher resolved disagreements. The number of food items for each processing group was determined and the mean (SD) percentage of TEI for each NOVA group was provided across participants. A 1-way analysis of variance and Tukey Multiple Comparisons Test were used to determine significance between groups with an α = .05 using Prism V9.

Results

Of the 92 participants in the original study, only 79 met inclusion criteria and had baseline diet data. The 79 veterans had a mean (SD) age of 61 (13) years and 59 (75%) were male (Table 1). Mean (SD) TEI was 1921 (815) kcal. The mean (SD) percentage of calories from carbohydrate, fat, and protein were 46% (21%), 39% (20%), and 16% (6%), respectively (Table 2).

A mean (SD) of 36 (12) food items were analyzed from the 3-day food records. The majority of food items were UPFs (56%), 33% were MPFs, 8% were PRFs, and 3% were CPFs. In total, 75% of TEI came from UPFs (P < .001); only 14% of TEI came from minimally processed foods (Figure).

Discussion

To our knowledge, this is the first analysis of UPF consumption among US veterans. TEIs coming from UPFs appear to be about 20% higher among veterans compared to nonveterans: 75% vs 55%.¹¹ Coupled with high UPF consumption, MPFs (14%) and PRFs (9%) represent smaller sources of TEI among surveyed veterans. Top caloric sources of UPFs in the US include sandwiches (including burgers), sweet bakery products, savory snacks, pizza, sweetened beverages, and breads, rolls, and tortillas, and likely reflect the major sources of UPFs in the veteran diet.¹³ As the statistical comparison between the veteran data and nonveteran data is not feasible in the present study, a future study with a much larger sample size would be needed for a direct comparison.

While the exact cause of higher UPF consumption among sampled veterans remains unknown and likely multifactorial (eg, cost, food insecurity, access, cooking skills, nutrition knowledge), veterans can receive a consult or self-refer to a registered dietitian nutritionist (RDN) for nutrition education. Counseling has been shown to be an effective way to improve diet quality and increase daily fruit and vegetable intake.¹⁴ High consumption of UPFs, which are generally energy-dense and nutrient-poor, contributes to the low diet quality observed in veterans, and future research examining the relationship between UPF intake and overall diet quality among veterans is warranted.^2,15 As nutrition knowledge is associated with higher diet quality among veterans, increased use of nutrition services (ie, nutrition education or food supplement programs) has the potential to influence consumption of MPFs and decrease consumption of UPFs.¹⁶ Subsequently, UPF-targeted interventions developed by VA RDNs hold the promise to decrease consumption of UPFs and increase intake of MPFs and PRFs.

Veterans have a high prevalence of diabetes, hypertension, and obesity.⁹ The high UPF intake observed in this sample of veterans may increase the risk for these chronic diseases and overall mortality. The high percentage of TEI from UPFs among veterans is also of concern not only due to potential negative health outcomes, but also associated costs of treating veterans with multimorbidities.¹⁷ Targeting UPF intake via nutritional education may promote health and decrease the financial burden needed to support the health of veterans.

Improving veteran health and well-being, including enhancing health care accessibility in underserved areas, are pivotal objectives of the VA strategic plan for 2026 to 2030. Public policy aims to tackle food insecurity within the veteran population during the first 5 years of civilian life.¹⁸ In alignment with the White House Strategy on Hunger, Nutrition, and Health, VA established a Food Security Office (FSO) in 2023. The FSO mission is to use an interdisciplinary approach to provide resources to ensure veteran food security and create an environment where all veterans are food and nutrition secure.

Limitations

This study has several limitations. As the Food Processor software database does not include all brand items, similar brands were used to mirror the nutrient profile. While food records are common among veteran diet studies, accuracy may be reduced due to self-reporting bias.¹⁹ Different interpretation of the NOVA classification designation for various food items is possible, however, 89% of foods were coded the same by the research team which suggests high accuracy in food coding. Specific ingredient information was not collected from the 3-day food records; thus, these records were not produced in such a way to improve the accuracy of the NOVA classification designation. This study was limited by its small sample size (N = 79); although, this analysis is larger than other studies of UPF consumption in the US.^20,21 In addition, the generalizability of this study is limited as this population sample was from a single VA hospital and may not reflect the overall veteran population. Participants in this study were recruited only from those receiving VA care, thus their diet quality may not represent the quality consumed by veterans not participating in VA services. Further research on UPF consumption among veterans is warranted with a larger, more representative study sample size.

Conclusions

As this is the highest observed UPF intake documented in the US, these results should be of concern for the VA and its RDNs. More research is needed to better understand why UPF consumption is so high among veterans, what barriers veterans face to decreasing UPF consumption, and what intervention(s) veterans would welcome to improve their diet quality. Presently, veterans are provided with access to a variety of effective nutrition education and counseling options and should be encouraged to use these services. VA RDNs should be aware of the high intake of UPFs in the veteran population and familiarize themselves with education and counseling strategies that promote behavior change to replace UPFs with more nutrient-dense foods choices.

Roughly 8.6% of the 17.4 million US veterans live in poverty. About 11.1% are considered food insecure (ie, unable to acquire adequate food for ≥1 household members), with another 5.3% considered very food insecure (ie, eating patterns of ≥1 household members were disrupted and their food intake was reduced at least some time during the year). Compared with nonveterans, veterans are 7.4% more likely to be food insecure.¹ This high prevalence of food insecurity and poverty has a negative impact on veteran diets.

Veterans’ diets contained more added sugars and solid fats and scored lower compared with nonveterans when assessed for diet quality with the Healthy Eating Index.² Veterans have a higher prevalence of diet-related chronic disease, including diabetes, hypertension, and obesity compared with the nonveterans.^3-5 Given the critical role of diet in health and disease risk, enhancing diet quality among veterans has garnered significant attention and calls to action.^2,6,7 While there are many factors that contribute to diet, any veteran can receive a consultation or self-refer to receive nutrition counseling effective for improving diet quality, within the US Department of Veterans Affairs (VA).

The NOVA food classification system describes diet quality by categorizing food items by processing methods and ingredients into 4 food groups.⁸ The first is unprocessed and minimally processed items (MPFs) such as fresh fruits, vegetables, and meats. MPFs consist of whole foods which can also be minimally processed (eg, chopping, drying, grinding, heating, chilling). Culinary processed foods (CPFs) are processed foods for cooking (eg, salt, butter, and vinegar) and are typically eaten in small quantities along with MPFs. Processed foods (PRFs) include canned and smoked foods, while ultra-processed foods (UPFs) are distinguished by industrial ingredients, requiring specialized tools and processing techniques, and hyper-palatability related to color, flavor, and packaging.⁸ Examples of UPFs include mass-produced breads found at grocery stores, prepackaged snacks and meals, and hydrogenated oils. UPF consumption is associated with higher risk for negative cardiometabolic outcomes, common mental disorders, and all-cause mortality.⁹ To date, only a study by Powell et al has used the NOVA classification system in a veteran population, and it was limited to a comparison of the price of UPFs and veteran body mass index (BMI).¹⁰ Therefore, it remains unknown what percentage of total energy intake (TEI) comes from UPFs in the diets of veterans.

This study sought to quantify the proportion of TEI from UPFs among a sample of patients from the VA Phoenix Health Care System (VAPHCS). Results from a 2021 global meta-analysis reveal that the US and United Kingdom have the highest intakes of UPFs in the world.¹¹ Specifically, within the US, 15 studies with 234,890 participants reveal that the majority of TEI (about 55%) comes from UPFs.¹¹ We hypothesized that this veteran sample would have a higher proportion of TEI from UPFs, possibly due to a higher prevalence of poverty and food insecurity among veterans compared with nonveterans.¹ If the percentage of TEI coming from UPF is higher or even similar to nonveterans, further efforts to increase veterans’ use of the available nutritional services would be warranted to minimize nutrition-related disease among veterans.

Methods

This is a cross-sectional, secondary data analysis of baseline 3-day food records collected from 2017 to 2020 from 92 patients recruited at VAPHCS to participate in a whole-food plant-based diet study.¹² The original study was reviewed and approved by the VAPHCS Institutional Review Board (1593830). Recruitment methods included clinician recommendation, a recorded advertisement played while phone calls were on hold, and flyers distributed throughout VAPHCS. Patients were included if they were aged 18 to 90 years, had a BMI 25.1 to 39.9, had a diagnosis of nutrition-related chronic disease (hypertension, diabetes, or hyperlipidemia), an interest and desire to make a lifestyle change, active telephone contact information (either landline or cell phone), no contraindication to be on a whole-food plant-based diet, access to transportation and a functioning kitchen, ability to prepare meals independently, access to a computer or tablet with internet access, and a digital camera or smartphone. Exclusion criteria included significant unplanned weight loss within 6 months, uncontrolled insulin-dependent diabetes with a current hemoglobin A_1c > 9%, pregnancy/lactation, taking prescribed weight loss medication, currently following a diet (eg, plant-based diet, vegan, or medical weight loss program diet), celiac disease diagnosed within 6 months, end-stage hepatic disease or renal disease requiring dialysis, active cancer or receiving chemotherapy or radiation therapy, active alcohol or substance use disorder, history of eating disorders, fasting triglyceride level > 350 mg/dL, any psychological issues that prevent adherence, inability to speak English, limited mobility, and homeless or in housing with limited kitchen access. A baseline 3-day food record was collected from the participants and used in this secondary analysis.

Diet Analysis

Food records were analyzed using Esha Research Food Processor 4.0 to identify calorie and macronutrient information. To limit bias, food items were coded independently by 2 researchers into 4 food processing groups determined by the NOVA classification: MPF, CPF, PRF, and UPF.⁸ When possible, specific ingredient information was collected using internet searches for brand product websites. Initial coding had an 89% agreement rate for food item coding between the 2 researchers. As coding was done in duplicate, a third researcher resolved disagreements. The number of food items for each processing group was determined and the mean (SD) percentage of TEI for each NOVA group was provided across participants. A 1-way analysis of variance and Tukey Multiple Comparisons Test were used to determine significance between groups with an α = .05 using Prism V9.

Results

Of the 92 participants in the original study, only 79 met inclusion criteria and had baseline diet data. The 79 veterans had a mean (SD) age of 61 (13) years and 59 (75%) were male (Table 1). Mean (SD) TEI was 1921 (815) kcal. The mean (SD) percentage of calories from carbohydrate, fat, and protein were 46% (21%), 39% (20%), and 16% (6%), respectively (Table 2).

A mean (SD) of 36 (12) food items were analyzed from the 3-day food records. The majority of food items were UPFs (56%), 33% were MPFs, 8% were PRFs, and 3% were CPFs. In total, 75% of TEI came from UPFs (P < .001); only 14% of TEI came from minimally processed foods (Figure).

Discussion

To our knowledge, this is the first analysis of UPF consumption among US veterans. TEIs coming from UPFs appear to be about 20% higher among veterans compared to nonveterans: 75% vs 55%.¹¹ Coupled with high UPF consumption, MPFs (14%) and PRFs (9%) represent smaller sources of TEI among surveyed veterans. Top caloric sources of UPFs in the US include sandwiches (including burgers), sweet bakery products, savory snacks, pizza, sweetened beverages, and breads, rolls, and tortillas, and likely reflect the major sources of UPFs in the veteran diet.¹³ As the statistical comparison between the veteran data and nonveteran data is not feasible in the present study, a future study with a much larger sample size would be needed for a direct comparison.

While the exact cause of higher UPF consumption among sampled veterans remains unknown and likely multifactorial (eg, cost, food insecurity, access, cooking skills, nutrition knowledge), veterans can receive a consult or self-refer to a registered dietitian nutritionist (RDN) for nutrition education. Counseling has been shown to be an effective way to improve diet quality and increase daily fruit and vegetable intake.¹⁴ High consumption of UPFs, which are generally energy-dense and nutrient-poor, contributes to the low diet quality observed in veterans, and future research examining the relationship between UPF intake and overall diet quality among veterans is warranted.^2,15 As nutrition knowledge is associated with higher diet quality among veterans, increased use of nutrition services (ie, nutrition education or food supplement programs) has the potential to influence consumption of MPFs and decrease consumption of UPFs.¹⁶ Subsequently, UPF-targeted interventions developed by VA RDNs hold the promise to decrease consumption of UPFs and increase intake of MPFs and PRFs.

Veterans have a high prevalence of diabetes, hypertension, and obesity.⁹ The high UPF intake observed in this sample of veterans may increase the risk for these chronic diseases and overall mortality. The high percentage of TEI from UPFs among veterans is also of concern not only due to potential negative health outcomes, but also associated costs of treating veterans with multimorbidities.¹⁷ Targeting UPF intake via nutritional education may promote health and decrease the financial burden needed to support the health of veterans.

Improving veteran health and well-being, including enhancing health care accessibility in underserved areas, are pivotal objectives of the VA strategic plan for 2026 to 2030. Public policy aims to tackle food insecurity within the veteran population during the first 5 years of civilian life.¹⁸ In alignment with the White House Strategy on Hunger, Nutrition, and Health, VA established a Food Security Office (FSO) in 2023. The FSO mission is to use an interdisciplinary approach to provide resources to ensure veteran food security and create an environment where all veterans are food and nutrition secure.

Limitations

This study has several limitations. As the Food Processor software database does not include all brand items, similar brands were used to mirror the nutrient profile. While food records are common among veteran diet studies, accuracy may be reduced due to self-reporting bias.¹⁹ Different interpretation of the NOVA classification designation for various food items is possible, however, 89% of foods were coded the same by the research team which suggests high accuracy in food coding. Specific ingredient information was not collected from the 3-day food records; thus, these records were not produced in such a way to improve the accuracy of the NOVA classification designation. This study was limited by its small sample size (N = 79); although, this analysis is larger than other studies of UPF consumption in the US.^20,21 In addition, the generalizability of this study is limited as this population sample was from a single VA hospital and may not reflect the overall veteran population. Participants in this study were recruited only from those receiving VA care, thus their diet quality may not represent the quality consumed by veterans not participating in VA services. Further research on UPF consumption among veterans is warranted with a larger, more representative study sample size.

Conclusions

As this is the highest observed UPF intake documented in the US, these results should be of concern for the VA and its RDNs. More research is needed to better understand why UPF consumption is so high among veterans, what barriers veterans face to decreasing UPF consumption, and what intervention(s) veterans would welcome to improve their diet quality. Presently, veterans are provided with access to a variety of effective nutrition education and counseling options and should be encouraged to use these services. VA RDNs should be aware of the high intake of UPFs in the veteran population and familiarize themselves with education and counseling strategies that promote behavior change to replace UPFs with more nutrient-dense foods choices.

Roughly 8.6% of the 17.4 million US veterans live in poverty. About 11.1% are considered food insecure (ie, unable to acquire adequate food for ≥1 household members), with another 5.3% considered very food insecure (ie, eating patterns of ≥1 household members were disrupted and their food intake was reduced at least some time during the year). Compared with nonveterans, veterans are 7.4% more likely to be food insecure.¹ This high prevalence of food insecurity and poverty has a negative impact on veteran diets.

Veterans’ diets contained more added sugars and solid fats and scored lower compared with nonveterans when assessed for diet quality with the Healthy Eating Index.² Veterans have a higher prevalence of diet-related chronic disease, including diabetes, hypertension, and obesity compared with the nonveterans.^3-5 Given the critical role of diet in health and disease risk, enhancing diet quality among veterans has garnered significant attention and calls to action.^2,6,7 While there are many factors that contribute to diet, any veteran can receive a consultation or self-refer to receive nutrition counseling effective for improving diet quality, within the US Department of Veterans Affairs (VA).

The NOVA food classification system describes diet quality by categorizing food items by processing methods and ingredients into 4 food groups.⁸ The first is unprocessed and minimally processed items (MPFs) such as fresh fruits, vegetables, and meats. MPFs consist of whole foods which can also be minimally processed (eg, chopping, drying, grinding, heating, chilling). Culinary processed foods (CPFs) are processed foods for cooking (eg, salt, butter, and vinegar) and are typically eaten in small quantities along with MPFs. Processed foods (PRFs) include canned and smoked foods, while ultra-processed foods (UPFs) are distinguished by industrial ingredients, requiring specialized tools and processing techniques, and hyper-palatability related to color, flavor, and packaging.⁸ Examples of UPFs include mass-produced breads found at grocery stores, prepackaged snacks and meals, and hydrogenated oils. UPF consumption is associated with higher risk for negative cardiometabolic outcomes, common mental disorders, and all-cause mortality.⁹ To date, only a study by Powell et al has used the NOVA classification system in a veteran population, and it was limited to a comparison of the price of UPFs and veteran body mass index (BMI).¹⁰ Therefore, it remains unknown what percentage of total energy intake (TEI) comes from UPFs in the diets of veterans.

This study sought to quantify the proportion of TEI from UPFs among a sample of patients from the VA Phoenix Health Care System (VAPHCS). Results from a 2021 global meta-analysis reveal that the US and United Kingdom have the highest intakes of UPFs in the world.¹¹ Specifically, within the US, 15 studies with 234,890 participants reveal that the majority of TEI (about 55%) comes from UPFs.¹¹ We hypothesized that this veteran sample would have a higher proportion of TEI from UPFs, possibly due to a higher prevalence of poverty and food insecurity among veterans compared with nonveterans.¹ If the percentage of TEI coming from UPF is higher or even similar to nonveterans, further efforts to increase veterans’ use of the available nutritional services would be warranted to minimize nutrition-related disease among veterans.

Methods

This is a cross-sectional, secondary data analysis of baseline 3-day food records collected from 2017 to 2020 from 92 patients recruited at VAPHCS to participate in a whole-food plant-based diet study.¹² The original study was reviewed and approved by the VAPHCS Institutional Review Board (1593830). Recruitment methods included clinician recommendation, a recorded advertisement played while phone calls were on hold, and flyers distributed throughout VAPHCS. Patients were included if they were aged 18 to 90 years, had a BMI 25.1 to 39.9, had a diagnosis of nutrition-related chronic disease (hypertension, diabetes, or hyperlipidemia), an interest and desire to make a lifestyle change, active telephone contact information (either landline or cell phone), no contraindication to be on a whole-food plant-based diet, access to transportation and a functioning kitchen, ability to prepare meals independently, access to a computer or tablet with internet access, and a digital camera or smartphone. Exclusion criteria included significant unplanned weight loss within 6 months, uncontrolled insulin-dependent diabetes with a current hemoglobin A_1c > 9%, pregnancy/lactation, taking prescribed weight loss medication, currently following a diet (eg, plant-based diet, vegan, or medical weight loss program diet), celiac disease diagnosed within 6 months, end-stage hepatic disease or renal disease requiring dialysis, active cancer or receiving chemotherapy or radiation therapy, active alcohol or substance use disorder, history of eating disorders, fasting triglyceride level > 350 mg/dL, any psychological issues that prevent adherence, inability to speak English, limited mobility, and homeless or in housing with limited kitchen access. A baseline 3-day food record was collected from the participants and used in this secondary analysis.

Diet Analysis

Food records were analyzed using Esha Research Food Processor 4.0 to identify calorie and macronutrient information. To limit bias, food items were coded independently by 2 researchers into 4 food processing groups determined by the NOVA classification: MPF, CPF, PRF, and UPF.⁸ When possible, specific ingredient information was collected using internet searches for brand product websites. Initial coding had an 89% agreement rate for food item coding between the 2 researchers. As coding was done in duplicate, a third researcher resolved disagreements. The number of food items for each processing group was determined and the mean (SD) percentage of TEI for each NOVA group was provided across participants. A 1-way analysis of variance and Tukey Multiple Comparisons Test were used to determine significance between groups with an α = .05 using Prism V9.

Results

Of the 92 participants in the original study, only 79 met inclusion criteria and had baseline diet data. The 79 veterans had a mean (SD) age of 61 (13) years and 59 (75%) were male (Table 1). Mean (SD) TEI was 1921 (815) kcal. The mean (SD) percentage of calories from carbohydrate, fat, and protein were 46% (21%), 39% (20%), and 16% (6%), respectively (Table 2).

A mean (SD) of 36 (12) food items were analyzed from the 3-day food records. The majority of food items were UPFs (56%), 33% were MPFs, 8% were PRFs, and 3% were CPFs. In total, 75% of TEI came from UPFs (P < .001); only 14% of TEI came from minimally processed foods (Figure).

Discussion

To our knowledge, this is the first analysis of UPF consumption among US veterans. TEIs coming from UPFs appear to be about 20% higher among veterans compared to nonveterans: 75% vs 55%.¹¹ Coupled with high UPF consumption, MPFs (14%) and PRFs (9%) represent smaller sources of TEI among surveyed veterans. Top caloric sources of UPFs in the US include sandwiches (including burgers), sweet bakery products, savory snacks, pizza, sweetened beverages, and breads, rolls, and tortillas, and likely reflect the major sources of UPFs in the veteran diet.¹³ As the statistical comparison between the veteran data and nonveteran data is not feasible in the present study, a future study with a much larger sample size would be needed for a direct comparison.

While the exact cause of higher UPF consumption among sampled veterans remains unknown and likely multifactorial (eg, cost, food insecurity, access, cooking skills, nutrition knowledge), veterans can receive a consult or self-refer to a registered dietitian nutritionist (RDN) for nutrition education. Counseling has been shown to be an effective way to improve diet quality and increase daily fruit and vegetable intake.¹⁴ High consumption of UPFs, which are generally energy-dense and nutrient-poor, contributes to the low diet quality observed in veterans, and future research examining the relationship between UPF intake and overall diet quality among veterans is warranted.^2,15 As nutrition knowledge is associated with higher diet quality among veterans, increased use of nutrition services (ie, nutrition education or food supplement programs) has the potential to influence consumption of MPFs and decrease consumption of UPFs.¹⁶ Subsequently, UPF-targeted interventions developed by VA RDNs hold the promise to decrease consumption of UPFs and increase intake of MPFs and PRFs.

Veterans have a high prevalence of diabetes, hypertension, and obesity.⁹ The high UPF intake observed in this sample of veterans may increase the risk for these chronic diseases and overall mortality. The high percentage of TEI from UPFs among veterans is also of concern not only due to potential negative health outcomes, but also associated costs of treating veterans with multimorbidities.¹⁷ Targeting UPF intake via nutritional education may promote health and decrease the financial burden needed to support the health of veterans.

Improving veteran health and well-being, including enhancing health care accessibility in underserved areas, are pivotal objectives of the VA strategic plan for 2026 to 2030. Public policy aims to tackle food insecurity within the veteran population during the first 5 years of civilian life.¹⁸ In alignment with the White House Strategy on Hunger, Nutrition, and Health, VA established a Food Security Office (FSO) in 2023. The FSO mission is to use an interdisciplinary approach to provide resources to ensure veteran food security and create an environment where all veterans are food and nutrition secure.

Limitations

This study has several limitations. As the Food Processor software database does not include all brand items, similar brands were used to mirror the nutrient profile. While food records are common among veteran diet studies, accuracy may be reduced due to self-reporting bias.¹⁹ Different interpretation of the NOVA classification designation for various food items is possible, however, 89% of foods were coded the same by the research team which suggests high accuracy in food coding. Specific ingredient information was not collected from the 3-day food records; thus, these records were not produced in such a way to improve the accuracy of the NOVA classification designation. This study was limited by its small sample size (N = 79); although, this analysis is larger than other studies of UPF consumption in the US.^20,21 In addition, the generalizability of this study is limited as this population sample was from a single VA hospital and may not reflect the overall veteran population. Participants in this study were recruited only from those receiving VA care, thus their diet quality may not represent the quality consumed by veterans not participating in VA services. Further research on UPF consumption among veterans is warranted with a larger, more representative study sample size.

Conclusions

As this is the highest observed UPF intake documented in the US, these results should be of concern for the VA and its RDNs. More research is needed to better understand why UPF consumption is so high among veterans, what barriers veterans face to decreasing UPF consumption, and what intervention(s) veterans would welcome to improve their diet quality. Presently, veterans are provided with access to a variety of effective nutrition education and counseling options and should be encouraged to use these services. VA RDNs should be aware of the high intake of UPFs in the veteran population and familiarize themselves with education and counseling strategies that promote behavior change to replace UPFs with more nutrient-dense foods choices.

While the incidence of lung cancer is decreasing in men, it continues to rise in women. With more than 19,000 new cases in France each year, lung cancer is now the third most commonly diagnosed cancer among women. This trend is also seen in other European countries but appears to be region-specific because other continents report a decline in incidence among women. Moreover, although overall prognosis remains better in the female population, the trend is worrying: Mortality associated with the disease is increasing in women, unlike in men with lung cancer. A session at the French-Language Pneumology Congress held from January 30 to February 1, 2026, in Lille, France, provided an opportunity to review the situation.

Efficacy and Toxicity

Lung tumors in women have a distinct tumor profile: Women have a higher proportion of adenocarcinomas than men and a higher frequency of somatic mutations (EGFR, BRAF, or HER2), including in nonsmokers. In addition, 65% of lung cancers in women are associated with smoking compared with 87% of those in men.

The role of estrogens is central because they interact directly with tumor growth signaling pathways. Moreover, “sex is the second leading factor of variability in drug pharmacokinetics after weight and accounts for 28% of anticancer drug kinetics,” emphasized Julien Mazières, pulmonologist, Toulouse University Hospital, Toulouse, France. Also involved in this equation are a higher body fat percentage, lower gastric acidity, and, above all, reduced renal and hepatic clearance.

As a result, exposure to drugs — represented by the area under the curve — is often greater in women and translates into not only improved progression-free survival with targeted therapies and chemotherapy but also increased toxicity. Carboplatin and paclitaxel are among the drugs whose kinetics are most affected by clearance. There are differences in clearance of more than 20% for these drugs in women vs men, though dosages are not systematically adjusted except for weight-based dosing. This vulnerability to adverse effects is particularly pronounced with targeted therapies, with more neuropsychiatric and gastrointestinal disorders. Data on the efficacy of immunotherapy in lung cancer by sex are contradictory. However, endocrine-related adverse effects and pneumonitis are more frequent in women, especially before menopause.

Women remain underrepresented in clinical trials, and sex-specific analyses of results are too rarely performed, which limits understanding of mechanisms and prevents tailoring management recommendations according to sex.

Impaired Quality of Life

Lung cancer most severely impairs physical functioning in women. “In the absence of sex-stratified studies, psycho-oncologists’ experience suggests that women have more cognitive disorders, anxiety, and depression associated with this disease. Its impact on quality of life is major, with deterioration of social relationships and reduced treatment adherence,” summarized Céline Mascaux, MD, PhD, pulmonologist, Strasbourg University Hospital, Strasbourg, France. Women also face social and family pressure — a mental burden that pushes them to “hold on” for their loved ones. Regarding sexual health, women with lung cancer who are sexually active often report dissatisfaction with the quality of their sexual relations because of fatigue, lack of energy, sadness, and shortness of breath, not to mention treatment-related sexual dysfunction. These problems are often not given sufficient attention by physicians.

Finally, fertility requires greater attention from the medical community: According to the VICAN study conducted by France’s National Health Insurance Fund, a discussion about fertility preservation did not take place at the time of cancer diagnosis for 60% of men and 67% of women of childbearing age. “In lung cancer specifically, the desire for children nevertheless exists in nearly 40% of patients of childbearing age,” regretted Jacques Cadranel, pulmonologist, Tenon Hospital, Paris, France. This desire does not appear to have influenced therapeutic strategy, and fertility preservation was ultimately proposed in only a third of cases and was carried out in only 3% of women compared with21% of men.

This story has been translated from Univadis France, part of the Medscape Professional Network.

A version of this story first appeared on Medscape.com

While the incidence of lung cancer is decreasing in men, it continues to rise in women. With more than 19,000 new cases in France each year, lung cancer is now the third most commonly diagnosed cancer among women. This trend is also seen in other European countries but appears to be region-specific because other continents report a decline in incidence among women. Moreover, although overall prognosis remains better in the female population, the trend is worrying: Mortality associated with the disease is increasing in women, unlike in men with lung cancer. A session at the French-Language Pneumology Congress held from January 30 to February 1, 2026, in Lille, France, provided an opportunity to review the situation.

Efficacy and Toxicity

Lung tumors in women have a distinct tumor profile: Women have a higher proportion of adenocarcinomas than men and a higher frequency of somatic mutations (EGFR, BRAF, or HER2), including in nonsmokers. In addition, 65% of lung cancers in women are associated with smoking compared with 87% of those in men.

The role of estrogens is central because they interact directly with tumor growth signaling pathways. Moreover, “sex is the second leading factor of variability in drug pharmacokinetics after weight and accounts for 28% of anticancer drug kinetics,” emphasized Julien Mazières, pulmonologist, Toulouse University Hospital, Toulouse, France. Also involved in this equation are a higher body fat percentage, lower gastric acidity, and, above all, reduced renal and hepatic clearance.

As a result, exposure to drugs — represented by the area under the curve — is often greater in women and translates into not only improved progression-free survival with targeted therapies and chemotherapy but also increased toxicity. Carboplatin and paclitaxel are among the drugs whose kinetics are most affected by clearance. There are differences in clearance of more than 20% for these drugs in women vs men, though dosages are not systematically adjusted except for weight-based dosing. This vulnerability to adverse effects is particularly pronounced with targeted therapies, with more neuropsychiatric and gastrointestinal disorders. Data on the efficacy of immunotherapy in lung cancer by sex are contradictory. However, endocrine-related adverse effects and pneumonitis are more frequent in women, especially before menopause.

Women remain underrepresented in clinical trials, and sex-specific analyses of results are too rarely performed, which limits understanding of mechanisms and prevents tailoring management recommendations according to sex.

Impaired Quality of Life

Lung cancer most severely impairs physical functioning in women. “In the absence of sex-stratified studies, psycho-oncologists’ experience suggests that women have more cognitive disorders, anxiety, and depression associated with this disease. Its impact on quality of life is major, with deterioration of social relationships and reduced treatment adherence,” summarized Céline Mascaux, MD, PhD, pulmonologist, Strasbourg University Hospital, Strasbourg, France. Women also face social and family pressure — a mental burden that pushes them to “hold on” for their loved ones. Regarding sexual health, women with lung cancer who are sexually active often report dissatisfaction with the quality of their sexual relations because of fatigue, lack of energy, sadness, and shortness of breath, not to mention treatment-related sexual dysfunction. These problems are often not given sufficient attention by physicians.

Finally, fertility requires greater attention from the medical community: According to the VICAN study conducted by France’s National Health Insurance Fund, a discussion about fertility preservation did not take place at the time of cancer diagnosis for 60% of men and 67% of women of childbearing age. “In lung cancer specifically, the desire for children nevertheless exists in nearly 40% of patients of childbearing age,” regretted Jacques Cadranel, pulmonologist, Tenon Hospital, Paris, France. This desire does not appear to have influenced therapeutic strategy, and fertility preservation was ultimately proposed in only a third of cases and was carried out in only 3% of women compared with21% of men.

This story has been translated from Univadis France, part of the Medscape Professional Network.

A version of this story first appeared on Medscape.com

While the incidence of lung cancer is decreasing in men, it continues to rise in women. With more than 19,000 new cases in France each year, lung cancer is now the third most commonly diagnosed cancer among women. This trend is also seen in other European countries but appears to be region-specific because other continents report a decline in incidence among women. Moreover, although overall prognosis remains better in the female population, the trend is worrying: Mortality associated with the disease is increasing in women, unlike in men with lung cancer. A session at the French-Language Pneumology Congress held from January 30 to February 1, 2026, in Lille, France, provided an opportunity to review the situation.

Efficacy and Toxicity

Lung tumors in women have a distinct tumor profile: Women have a higher proportion of adenocarcinomas than men and a higher frequency of somatic mutations (EGFR, BRAF, or HER2), including in nonsmokers. In addition, 65% of lung cancers in women are associated with smoking compared with 87% of those in men.

The role of estrogens is central because they interact directly with tumor growth signaling pathways. Moreover, “sex is the second leading factor of variability in drug pharmacokinetics after weight and accounts for 28% of anticancer drug kinetics,” emphasized Julien Mazières, pulmonologist, Toulouse University Hospital, Toulouse, France. Also involved in this equation are a higher body fat percentage, lower gastric acidity, and, above all, reduced renal and hepatic clearance.

As a result, exposure to drugs — represented by the area under the curve — is often greater in women and translates into not only improved progression-free survival with targeted therapies and chemotherapy but also increased toxicity. Carboplatin and paclitaxel are among the drugs whose kinetics are most affected by clearance. There are differences in clearance of more than 20% for these drugs in women vs men, though dosages are not systematically adjusted except for weight-based dosing. This vulnerability to adverse effects is particularly pronounced with targeted therapies, with more neuropsychiatric and gastrointestinal disorders. Data on the efficacy of immunotherapy in lung cancer by sex are contradictory. However, endocrine-related adverse effects and pneumonitis are more frequent in women, especially before menopause.

Women remain underrepresented in clinical trials, and sex-specific analyses of results are too rarely performed, which limits understanding of mechanisms and prevents tailoring management recommendations according to sex.

Impaired Quality of Life

Lung cancer most severely impairs physical functioning in women. “In the absence of sex-stratified studies, psycho-oncologists’ experience suggests that women have more cognitive disorders, anxiety, and depression associated with this disease. Its impact on quality of life is major, with deterioration of social relationships and reduced treatment adherence,” summarized Céline Mascaux, MD, PhD, pulmonologist, Strasbourg University Hospital, Strasbourg, France. Women also face social and family pressure — a mental burden that pushes them to “hold on” for their loved ones. Regarding sexual health, women with lung cancer who are sexually active often report dissatisfaction with the quality of their sexual relations because of fatigue, lack of energy, sadness, and shortness of breath, not to mention treatment-related sexual dysfunction. These problems are often not given sufficient attention by physicians.

Finally, fertility requires greater attention from the medical community: According to the VICAN study conducted by France’s National Health Insurance Fund, a discussion about fertility preservation did not take place at the time of cancer diagnosis for 60% of men and 67% of women of childbearing age. “In lung cancer specifically, the desire for children nevertheless exists in nearly 40% of patients of childbearing age,” regretted Jacques Cadranel, pulmonologist, Tenon Hospital, Paris, France. This desire does not appear to have influenced therapeutic strategy, and fertility preservation was ultimately proposed in only a third of cases and was carried out in only 3% of women compared with21% of men.

This story has been translated from Univadis France, part of the Medscape Professional Network.

A version of this story first appeared on Medscape.com

TOPLINE:

In a review of physician-related malpractice cases from 1930 to 2025, melanoma was the most frequently litigated skin cancer, and failure or delay in diagnosis was the most common allegation, with documented death in nearly one third of cases.

METHODOLOGY:

Researchers conducted a review of physician-related medicolegal cases involving skin cancer using the LexisNexis legal database and identified 188 unique cases from 1930 through May 2025.

Cases were included if physicians were named as defendants and the litigation centered on diagnosis or management of a cutaneous malignancy.

Study outcomes examined case characteristics including cancer type, practice setting, defendant specialty, primary allegations, clinical outcomes, and case verdicts across the US.

TAKEAWAY:

Melanoma accounted for 49.5% of litigated cases, followed by squamous cell carcinoma (21.6%), basal cell carcinoma (14.2%), unspecified skin cancer (11.6%), and other rare tumors (3.1%). Death was reported in 29.8% of cases and metastatic disease in 39.9%.

Failure or delay in diagnosis was the leading allegation (38.1%), followed by treatment or management errors (24.2%), misdiagnosis (11.4%), “deliberate indifference” (8.3%), inadequate informed consent (7.5%), and pathology-related errors (7.2%).

Family physicians were the most common defendants (27.5%), followed by dermatologists, including Mohs surgeons (20.1%), and pathologists or dermatopathologists (14.4%), followed by general or plastic surgeons (7.9%), and internists (4.4%). Most cases originated in private practices (59.7%), and New York (16.0%) and California (13.3%) were the states with the most cases.

Among 109 closed cases, 5.5% resulted in plaintiff verdicts, whereas defense verdicts predominated in 55.0%. Plaintiff awards ranged from $10,000 to $4.25 million.

IN PRACTICE:

“This comprehensive review demonstrates that melanoma is the most frequently litigated skin cancer, particularly in cases involving metastatic disease or death, and that family physicians are the most commonly named defendants overall,” the authors wrote. “By examining both allegations and outcomes,” they added, “this analysis provides a pragmatic assessment of real-world litigation exposure and the clinical scenarios that expose physicians to legal proceedings, financial cost, reputational harm, and psychological burden, regardless of case disposition.”

SOURCE:

The study was led by Ghassan Barnawi, MD, Division of Dermatology, McGill University in Montreal, Quebec, Canada, and was published online on February 20, 2026, in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The study relied on published court decisions, which likely underestimated malpractice burden by excluding settlements and unreported claims.

DISCLOSURES:

The study did not receive any funding. The authors reported having no relevant conflicts of interest.

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

The study had no commercial funding. The authors had no relevant disclosures.

A version of this article first appeared on Medscape.com

TOPLINE:

In a review of physician-related malpractice cases from 1930 to 2025, melanoma was the most frequently litigated skin cancer, and failure or delay in diagnosis was the most common allegation, with documented death in nearly one third of cases.

METHODOLOGY:

Researchers conducted a review of physician-related medicolegal cases involving skin cancer using the LexisNexis legal database and identified 188 unique cases from 1930 through May 2025.

Cases were included if physicians were named as defendants and the litigation centered on diagnosis or management of a cutaneous malignancy.

Study outcomes examined case characteristics including cancer type, practice setting, defendant specialty, primary allegations, clinical outcomes, and case verdicts across the US.

TAKEAWAY:

Melanoma accounted for 49.5% of litigated cases, followed by squamous cell carcinoma (21.6%), basal cell carcinoma (14.2%), unspecified skin cancer (11.6%), and other rare tumors (3.1%). Death was reported in 29.8% of cases and metastatic disease in 39.9%.

Failure or delay in diagnosis was the leading allegation (38.1%), followed by treatment or management errors (24.2%), misdiagnosis (11.4%), “deliberate indifference” (8.3%), inadequate informed consent (7.5%), and pathology-related errors (7.2%).

Family physicians were the most common defendants (27.5%), followed by dermatologists, including Mohs surgeons (20.1%), and pathologists or dermatopathologists (14.4%), followed by general or plastic surgeons (7.9%), and internists (4.4%). Most cases originated in private practices (59.7%), and New York (16.0%) and California (13.3%) were the states with the most cases.

Among 109 closed cases, 5.5% resulted in plaintiff verdicts, whereas defense verdicts predominated in 55.0%. Plaintiff awards ranged from $10,000 to $4.25 million.

IN PRACTICE:

“This comprehensive review demonstrates that melanoma is the most frequently litigated skin cancer, particularly in cases involving metastatic disease or death, and that family physicians are the most commonly named defendants overall,” the authors wrote. “By examining both allegations and outcomes,” they added, “this analysis provides a pragmatic assessment of real-world litigation exposure and the clinical scenarios that expose physicians to legal proceedings, financial cost, reputational harm, and psychological burden, regardless of case disposition.”

SOURCE:

The study was led by Ghassan Barnawi, MD, Division of Dermatology, McGill University in Montreal, Quebec, Canada, and was published online on February 20, 2026, in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The study relied on published court decisions, which likely underestimated malpractice burden by excluding settlements and unreported claims.

DISCLOSURES:

The study did not receive any funding. The authors reported having no relevant conflicts of interest.

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

The study had no commercial funding. The authors had no relevant disclosures.

A version of this article first appeared on Medscape.com

TOPLINE:

In a review of physician-related malpractice cases from 1930 to 2025, melanoma was the most frequently litigated skin cancer, and failure or delay in diagnosis was the most common allegation, with documented death in nearly one third of cases.

METHODOLOGY:

Researchers conducted a review of physician-related medicolegal cases involving skin cancer using the LexisNexis legal database and identified 188 unique cases from 1930 through May 2025.

Cases were included if physicians were named as defendants and the litigation centered on diagnosis or management of a cutaneous malignancy.

Study outcomes examined case characteristics including cancer type, practice setting, defendant specialty, primary allegations, clinical outcomes, and case verdicts across the US.

TAKEAWAY:

Melanoma accounted for 49.5% of litigated cases, followed by squamous cell carcinoma (21.6%), basal cell carcinoma (14.2%), unspecified skin cancer (11.6%), and other rare tumors (3.1%). Death was reported in 29.8% of cases and metastatic disease in 39.9%.

Failure or delay in diagnosis was the leading allegation (38.1%), followed by treatment or management errors (24.2%), misdiagnosis (11.4%), “deliberate indifference” (8.3%), inadequate informed consent (7.5%), and pathology-related errors (7.2%).

Family physicians were the most common defendants (27.5%), followed by dermatologists, including Mohs surgeons (20.1%), and pathologists or dermatopathologists (14.4%), followed by general or plastic surgeons (7.9%), and internists (4.4%). Most cases originated in private practices (59.7%), and New York (16.0%) and California (13.3%) were the states with the most cases.

Among 109 closed cases, 5.5% resulted in plaintiff verdicts, whereas defense verdicts predominated in 55.0%. Plaintiff awards ranged from $10,000 to $4.25 million.

IN PRACTICE:

“This comprehensive review demonstrates that melanoma is the most frequently litigated skin cancer, particularly in cases involving metastatic disease or death, and that family physicians are the most commonly named defendants overall,” the authors wrote. “By examining both allegations and outcomes,” they added, “this analysis provides a pragmatic assessment of real-world litigation exposure and the clinical scenarios that expose physicians to legal proceedings, financial cost, reputational harm, and psychological burden, regardless of case disposition.”

SOURCE:

The study was led by Ghassan Barnawi, MD, Division of Dermatology, McGill University in Montreal, Quebec, Canada, and was published online on February 20, 2026, in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The study relied on published court decisions, which likely underestimated malpractice burden by excluding settlements and unreported claims.

DISCLOSURES:

The study did not receive any funding. The authors reported having no relevant conflicts of interest.

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

The study had no commercial funding. The authors had no relevant disclosures.

A version of this article first appeared on Medscape.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New research challenges the assumption that long-term cannabis use improves symptoms or functioning in posttraumatic stress disorder (PTSD).

On the contrary, researchers found that abstaining from cannabis for 3 months was associated with significantly greater reductions in PTSD symptoms in adults with PTSD and comorbid cannabis use disorder (CUD).

The data suggest that continued cannabis use could limit recovery in some domains — underscoring the need to routinely assess cannabis use during PTSD treatment and to educate patients on the potential consequences of continued use, the researchers said. 

The study was published online February 18 in the Journal of Clinical Psychiatry. 

Helpful or Harmful? 

PTSD is a debilitating psychiatric condition marked by intrusive memories, avoidance, negative changes in mood and cognition, and hyperarousal. Many patients turn to cannabis to ease symptoms. In one recent study, roughly 28% of individuals with PTSD reported past-year cannabis use and 9% met criteria for CUD. 

Although some studies have suggested PTSD symptom reduction with cannabis or cannabinoid-based treatments, others have identified potential risks, such as disrupted fear-extinction learning and worse clinical and treatment outcomes. 

A recent systematic review found mixed evidence overall, with six studies suggesting benefits, five reporting worsening of symptoms, and three showing no significant impact of cannabis use in the setting of PTSD.

Led by Ahmed Hassan, MD, University of Toronto, Ontario, the researchers recruited adults aged 18-65 years with confirmed PTSD and CUD through the Centre for Addiction and Mental Health in Toronto and asked them to discontinue cannabis for 12 weeks.

Abstinence was defined as a urine 11-nor-9-carboxy-tetrahydrocannabinol level of 50 ng/mL or lower with no self-reported use, verified at multiple timepoints. Participants received escalating cash incentives for remaining abstinent at weeks 4, 8, and 12.

Eleven (52%) of the 21 participants who completed the 12-week protocol achieved biochemically verified abstinence, while 10 did not.

Those who achieved abstinence reported significantly greater reductions in total PTSD symptom severity and symptom count compared to those who did not. 

Total severity scores on the Clinician-Administered PTSD Scale for DSM-5 dropped from 36.2 at baseline to 10.5 at week 12 among abstainers vs 34.6 to 21.8 among those who did not maintain abstinence (P = .001).

A similar pattern emerged for total symptom count, with abstinent participants dropping from 14.3 symptoms at baseline to 4.1 at week 12, compared to a decrease from 13.5 to 8.9 among nonabstainers.

Notably, the investigators observed that individuals who remained abstinent showed greater reductions in several core symptom clusters, including avoidance, negative alterations in mood, cognition, and hyperarousal — domains that are often cited as targets for cannabis-based self-medication among individuals with PTSD. 

“However, in this comorbid PTSD and CUD sample, sustained cannabis abstinence was associated with symptom improvement, thereby challenging assumptions about its clinical utility in this population,” they wrote. 

Interestingly, they added that there were no differential effects on reexperiencing symptoms such as flashbacks, intrusive memories, and nightmares. Both abstinent and nonabstinent participants reported similar improvements in reexperiencing, suggesting that factors unrelated to cannabis use may have contributed to symptom change or insufficient power, the authors said. 

The researchers called for larger randomized trials to “replicate and extend” these preliminary findings and to investigate mechanisms through which abstinence may relate to symptom changes in PTSD with CUD.

The study had no commercial funding. The authors had no relevant disclosures.

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

New research challenges the assumption that long-term cannabis use improves symptoms or functioning in posttraumatic stress disorder (PTSD).

On the contrary, researchers found that abstaining from cannabis for 3 months was associated with significantly greater reductions in PTSD symptoms in adults with PTSD and comorbid cannabis use disorder (CUD).

The data suggest that continued cannabis use could limit recovery in some domains — underscoring the need to routinely assess cannabis use during PTSD treatment and to educate patients on the potential consequences of continued use, the researchers said. 

The study was published online February 18 in the Journal of Clinical Psychiatry. 

Helpful or Harmful? 

PTSD is a debilitating psychiatric condition marked by intrusive memories, avoidance, negative changes in mood and cognition, and hyperarousal. Many patients turn to cannabis to ease symptoms. In one recent study, roughly 28% of individuals with PTSD reported past-year cannabis use and 9% met criteria for CUD. 

Although some studies have suggested PTSD symptom reduction with cannabis or cannabinoid-based treatments, others have identified potential risks, such as disrupted fear-extinction learning and worse clinical and treatment outcomes. 

A recent systematic review found mixed evidence overall, with six studies suggesting benefits, five reporting worsening of symptoms, and three showing no significant impact of cannabis use in the setting of PTSD.

Led by Ahmed Hassan, MD, University of Toronto, Ontario, the researchers recruited adults aged 18-65 years with confirmed PTSD and CUD through the Centre for Addiction and Mental Health in Toronto and asked them to discontinue cannabis for 12 weeks.

Abstinence was defined as a urine 11-nor-9-carboxy-tetrahydrocannabinol level of 50 ng/mL or lower with no self-reported use, verified at multiple timepoints. Participants received escalating cash incentives for remaining abstinent at weeks 4, 8, and 12.

Eleven (52%) of the 21 participants who completed the 12-week protocol achieved biochemically verified abstinence, while 10 did not.

Those who achieved abstinence reported significantly greater reductions in total PTSD symptom severity and symptom count compared to those who did not. 

Total severity scores on the Clinician-Administered PTSD Scale for DSM-5 dropped from 36.2 at baseline to 10.5 at week 12 among abstainers vs 34.6 to 21.8 among those who did not maintain abstinence (P = .001).

A similar pattern emerged for total symptom count, with abstinent participants dropping from 14.3 symptoms at baseline to 4.1 at week 12, compared to a decrease from 13.5 to 8.9 among nonabstainers.

Notably, the investigators observed that individuals who remained abstinent showed greater reductions in several core symptom clusters, including avoidance, negative alterations in mood, cognition, and hyperarousal — domains that are often cited as targets for cannabis-based self-medication among individuals with PTSD. 

“However, in this comorbid PTSD and CUD sample, sustained cannabis abstinence was associated with symptom improvement, thereby challenging assumptions about its clinical utility in this population,” they wrote. 

Interestingly, they added that there were no differential effects on reexperiencing symptoms such as flashbacks, intrusive memories, and nightmares. Both abstinent and nonabstinent participants reported similar improvements in reexperiencing, suggesting that factors unrelated to cannabis use may have contributed to symptom change or insufficient power, the authors said. 

The researchers called for larger randomized trials to “replicate and extend” these preliminary findings and to investigate mechanisms through which abstinence may relate to symptom changes in PTSD with CUD.

The study had no commercial funding. The authors had no relevant disclosures.

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

New research challenges the assumption that long-term cannabis use improves symptoms or functioning in posttraumatic stress disorder (PTSD).

On the contrary, researchers found that abstaining from cannabis for 3 months was associated with significantly greater reductions in PTSD symptoms in adults with PTSD and comorbid cannabis use disorder (CUD).

The data suggest that continued cannabis use could limit recovery in some domains — underscoring the need to routinely assess cannabis use during PTSD treatment and to educate patients on the potential consequences of continued use, the researchers said. 

The study was published online February 18 in the Journal of Clinical Psychiatry. 

Helpful or Harmful? 

PTSD is a debilitating psychiatric condition marked by intrusive memories, avoidance, negative changes in mood and cognition, and hyperarousal. Many patients turn to cannabis to ease symptoms. In one recent study, roughly 28% of individuals with PTSD reported past-year cannabis use and 9% met criteria for CUD. 

Although some studies have suggested PTSD symptom reduction with cannabis or cannabinoid-based treatments, others have identified potential risks, such as disrupted fear-extinction learning and worse clinical and treatment outcomes. 

A recent systematic review found mixed evidence overall, with six studies suggesting benefits, five reporting worsening of symptoms, and three showing no significant impact of cannabis use in the setting of PTSD.

Led by Ahmed Hassan, MD, University of Toronto, Ontario, the researchers recruited adults aged 18-65 years with confirmed PTSD and CUD through the Centre for Addiction and Mental Health in Toronto and asked them to discontinue cannabis for 12 weeks.

Abstinence was defined as a urine 11-nor-9-carboxy-tetrahydrocannabinol level of 50 ng/mL or lower with no self-reported use, verified at multiple timepoints. Participants received escalating cash incentives for remaining abstinent at weeks 4, 8, and 12.

Eleven (52%) of the 21 participants who completed the 12-week protocol achieved biochemically verified abstinence, while 10 did not.

Those who achieved abstinence reported significantly greater reductions in total PTSD symptom severity and symptom count compared to those who did not. 

Total severity scores on the Clinician-Administered PTSD Scale for DSM-5 dropped from 36.2 at baseline to 10.5 at week 12 among abstainers vs 34.6 to 21.8 among those who did not maintain abstinence (P = .001).

A similar pattern emerged for total symptom count, with abstinent participants dropping from 14.3 symptoms at baseline to 4.1 at week 12, compared to a decrease from 13.5 to 8.9 among nonabstainers.

Notably, the investigators observed that individuals who remained abstinent showed greater reductions in several core symptom clusters, including avoidance, negative alterations in mood, cognition, and hyperarousal — domains that are often cited as targets for cannabis-based self-medication among individuals with PTSD. 

“However, in this comorbid PTSD and CUD sample, sustained cannabis abstinence was associated with symptom improvement, thereby challenging assumptions about its clinical utility in this population,” they wrote. 

Interestingly, they added that there were no differential effects on reexperiencing symptoms such as flashbacks, intrusive memories, and nightmares. Both abstinent and nonabstinent participants reported similar improvements in reexperiencing, suggesting that factors unrelated to cannabis use may have contributed to symptom change or insufficient power, the authors said. 

The researchers called for larger randomized trials to “replicate and extend” these preliminary findings and to investigate mechanisms through which abstinence may relate to symptom changes in PTSD with CUD.

The study had no commercial funding. The authors had no relevant disclosures.

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

Patients with advanced cancer treated with immune checkpoint inhibitors appear to have a survival benefit if they receive influenza vaccination, a new retrospective analysis found. The results also suggest no increase in the risk for immune-related adverse events (IRAEs) in these patients and that the improvement in survival outcomes may be stronger among those with cutaneous malignant melanoma.

“Our findings align with a growing body of evidence, mainly from retrospective studies, that suggest a potential association between influenza vaccination during immune checkpoint inhibitor treatment and improved survival among patients with cancer,” wrote senior author Antonis Valachis, MD, PhD, and colleagues in an article published in JCO Clinical Practice on February 9. “An additional clinically relevant observation is that the association between influenza vaccination and survival may vary by tumor type.”

The new research supports “current recommendations to offer influenza vaccination to all patients undergoing cancer therapy, including those receiving the drugs,” Valachis, of the Department of Oncology, Örebro University in Örebro, Sweden, and his coauthors wrote.

“What we observed is that influenza vaccination is safe for patients under immunotherapy treatment,” Valachis told Medscape Medical News. But “whether influenza vaccination can be used to boost immunotherapy effectiveness should be tested in a study with a different design,” such as a prospective interventional trial.

Discussing potential explanations for why influenza vaccination could affect immunotherapy outcomes without affecting rates of IRAEs, Valachis said that this “cannot be answered within the constraints of our study design, since all patients were treated with immunotherapy.”

It may nevertheless be hypothesized that “immune activation triggered by vaccination preferentially stimulates immune mechanisms that enhance immunotherapy efficacy, while sparing those that contribute to IRAEs.”

Steady Was 'Relatively Modestly Sized'

Question marks were raised over the study itself and, as a result, its findings.

Justin Jee, MD, PhD, a thoracic medical oncologist at Memorial Sloan Kettering Cancer Center, New York City, told Medscape Medical News that there are “a lot of challenges when looking at retrospective data.”

“The authors did a very reasonable job of trying to control for confounders and certain time dependent issues, like immortality bias,” he said. “That said, it’s a relatively modestly sized retrospective study for looking at something that has enormous potential for confounding bias that really can’t be captured with any standard statistical method.”

Jee pointed to factors such as providers potentially being more likely to refer people for vaccination if they’re healthier “vs if the patient is in hospice care,” or individuals simply not getting vaccinated because it is not uppermost in their mind.

“Those things are very, very difficult to control for.”

Jee also said he believes the benefit with influenza vaccination being stronger in cutaneous malignant melanoma could be a study artifact, while the lack of difference in rates of IRAEs could be the result of selection bias, but “it’s just impossible to say with a study like this.”

“I’ve seen several studies looking at both COVID and flu vaccines and whether or not they improve immune checkpoint blockade efficacy,” he added, explaining that “some of them say COVID vaccine good, flu vaccine not as good; others say both flu and COVID vaccines good; others say flu vaccine good, COVID vaccine not as good.”

All Patients With Cancer Should Be Vaccinated

What is clear is that “patients with cancer are [at] especially high risk of developing complications from viral illnesses, including flu, including COVID, and vaccines are a very important part of reducing morbidity, mortality, and spread,” Jee said. The “big picture” is that everyone should get the influenza vaccine, especially patients with cancer, “so in that sense I agree with that part of the conclusion of the paper” and that’s “an important message.”

Mini Kamboj, MD, chief medical epidemiologist at Memorial Sloan Kettering Cancer Center, agreed, saying that the results are “consistent with other research showing that vaccines are safe and beneficial for patients on checkpoint inhibitors.”

“While vaccinated patients with melanoma showed the greatest survival benefit, the authors note small sample size and unrecognized differences between the groups as a potential explanation for their findings. This does not change vaccine recommendations as evidence already supports flu vaccine safety and effectiveness in people with lung cancer on checkpoint inhibitors.”

Nearly 600 Patients With Advanced Cancer

The researchers performed a retrospective cohort study of patients from three regions in Sweden who had advanced solid tumors and were treated with PD-1 or PD-L1 inhibitor monotherapy, or PD-1 combination therapy with a cytotoxic T-lymphocyte-associated protein 4 inhibitor, between January 1, 2016, until December 31, 2021. Treatment was given either routinely or as part of a clinical trial.

Electronic medical records were examined to gather data on a range of variables, including age at diagnosis, sex, Charlson Comorbidity Index, type of cancer, primary treatment at diagnosis, number of previous lines of treatment, best treatment response, IRAEs, influenza vaccination status, and date and cause of death.

In all, 587 patients were treated with immune checkpoint inhibition over the study period. They had a median age of 66 years, and 58.1% were men. The most common malignancies were nonsmall cell lung cancer (NSCLC), cutaneous malignant melanoma (32.5%), and renal cell carcinoma (14.7%).

The most commonly used immune checkpoint inhibitor was nivolumab, which was administered to 47.9% of patients, followed by pembrolizumab (34.6%), atezolizumab (9.4%), and nivolumab plus ipilimumab (6.8%).

Only Patients With Malignant Melanoma Benefit

Over the study period, 17.7% of patients underwent influenza vaccination, at a median time between initiation of immune checkpoint inhibition and vaccination of 2 months. Ninety per cent of patients received the vaccine within 9 months of starting treatment.

Time-dependent Cox regression analysis revealed that real-world progression-free survival (rwPFS) was significantly longer with vaccinated patients than unvaccinated patients at a hazard ratio of 0.59 (95% CI, 0.44-0.79), as was overall survival, at a hazard ratio of 0.56 (95% CI, 0.42-0.75).

There was no significant difference in rwPFS and overall survival between vaccinated and unvaccinated patients among those with NSCLC, but significant differences were seen in those with cutaneous malignant melanoma, at hazard ratios of 0.58 (95% CI, 0.36-0.96) and 0.58 (95% CI, 0.36-0.96), respectively.

Restricting the analysis to immune checkpoint inhibitor monotherapy indicated that vaccinated patients had significantly longer rwPFS and overall survival than unvaccinated patients, at hazard ratios of 0.58 (95% CI, 0.43-0.79) and 0.50 (95% CI, 0.38-0.76), respectively.

Finally, the team found that there were no significant differences in the rates of any grade IRAEs between vaccinated and unvaccinated patients, at 48.4% vs 51.2% (P = .455), or in rates of multiple IRAEs, at 15.1% vs 19.2% (P = .297). The therapeutic management and outcomes of IRAEs were also comparable.

No funding or relevant financial relationships were declared.

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

Patients with advanced cancer treated with immune checkpoint inhibitors appear to have a survival benefit if they receive influenza vaccination, a new retrospective analysis found. The results also suggest no increase in the risk for immune-related adverse events (IRAEs) in these patients and that the improvement in survival outcomes may be stronger among those with cutaneous malignant melanoma.

“Our findings align with a growing body of evidence, mainly from retrospective studies, that suggest a potential association between influenza vaccination during immune checkpoint inhibitor treatment and improved survival among patients with cancer,” wrote senior author Antonis Valachis, MD, PhD, and colleagues in an article published in JCO Clinical Practice on February 9. “An additional clinically relevant observation is that the association between influenza vaccination and survival may vary by tumor type.”

The new research supports “current recommendations to offer influenza vaccination to all patients undergoing cancer therapy, including those receiving the drugs,” Valachis, of the Department of Oncology, Örebro University in Örebro, Sweden, and his coauthors wrote.

“What we observed is that influenza vaccination is safe for patients under immunotherapy treatment,” Valachis told Medscape Medical News. But “whether influenza vaccination can be used to boost immunotherapy effectiveness should be tested in a study with a different design,” such as a prospective interventional trial.

Discussing potential explanations for why influenza vaccination could affect immunotherapy outcomes without affecting rates of IRAEs, Valachis said that this “cannot be answered within the constraints of our study design, since all patients were treated with immunotherapy.”

It may nevertheless be hypothesized that “immune activation triggered by vaccination preferentially stimulates immune mechanisms that enhance immunotherapy efficacy, while sparing those that contribute to IRAEs.”

Steady Was 'Relatively Modestly Sized'

Question marks were raised over the study itself and, as a result, its findings.

Justin Jee, MD, PhD, a thoracic medical oncologist at Memorial Sloan Kettering Cancer Center, New York City, told Medscape Medical News that there are “a lot of challenges when looking at retrospective data.”

“The authors did a very reasonable job of trying to control for confounders and certain time dependent issues, like immortality bias,” he said. “That said, it’s a relatively modestly sized retrospective study for looking at something that has enormous potential for confounding bias that really can’t be captured with any standard statistical method.”

Jee pointed to factors such as providers potentially being more likely to refer people for vaccination if they’re healthier “vs if the patient is in hospice care,” or individuals simply not getting vaccinated because it is not uppermost in their mind.

“Those things are very, very difficult to control for.”

Jee also said he believes the benefit with influenza vaccination being stronger in cutaneous malignant melanoma could be a study artifact, while the lack of difference in rates of IRAEs could be the result of selection bias, but “it’s just impossible to say with a study like this.”

“I’ve seen several studies looking at both COVID and flu vaccines and whether or not they improve immune checkpoint blockade efficacy,” he added, explaining that “some of them say COVID vaccine good, flu vaccine not as good; others say both flu and COVID vaccines good; others say flu vaccine good, COVID vaccine not as good.”

All Patients With Cancer Should Be Vaccinated

What is clear is that “patients with cancer are [at] especially high risk of developing complications from viral illnesses, including flu, including COVID, and vaccines are a very important part of reducing morbidity, mortality, and spread,” Jee said. The “big picture” is that everyone should get the influenza vaccine, especially patients with cancer, “so in that sense I agree with that part of the conclusion of the paper” and that’s “an important message.”

Mini Kamboj, MD, chief medical epidemiologist at Memorial Sloan Kettering Cancer Center, agreed, saying that the results are “consistent with other research showing that vaccines are safe and beneficial for patients on checkpoint inhibitors.”

“While vaccinated patients with melanoma showed the greatest survival benefit, the authors note small sample size and unrecognized differences between the groups as a potential explanation for their findings. This does not change vaccine recommendations as evidence already supports flu vaccine safety and effectiveness in people with lung cancer on checkpoint inhibitors.”

Nearly 600 Patients With Advanced Cancer

The researchers performed a retrospective cohort study of patients from three regions in Sweden who had advanced solid tumors and were treated with PD-1 or PD-L1 inhibitor monotherapy, or PD-1 combination therapy with a cytotoxic T-lymphocyte-associated protein 4 inhibitor, between January 1, 2016, until December 31, 2021. Treatment was given either routinely or as part of a clinical trial.

Electronic medical records were examined to gather data on a range of variables, including age at diagnosis, sex, Charlson Comorbidity Index, type of cancer, primary treatment at diagnosis, number of previous lines of treatment, best treatment response, IRAEs, influenza vaccination status, and date and cause of death.

In all, 587 patients were treated with immune checkpoint inhibition over the study period. They had a median age of 66 years, and 58.1% were men. The most common malignancies were nonsmall cell lung cancer (NSCLC), cutaneous malignant melanoma (32.5%), and renal cell carcinoma (14.7%).

The most commonly used immune checkpoint inhibitor was nivolumab, which was administered to 47.9% of patients, followed by pembrolizumab (34.6%), atezolizumab (9.4%), and nivolumab plus ipilimumab (6.8%).

Only Patients With Malignant Melanoma Benefit

Over the study period, 17.7% of patients underwent influenza vaccination, at a median time between initiation of immune checkpoint inhibition and vaccination of 2 months. Ninety per cent of patients received the vaccine within 9 months of starting treatment.

Time-dependent Cox regression analysis revealed that real-world progression-free survival (rwPFS) was significantly longer with vaccinated patients than unvaccinated patients at a hazard ratio of 0.59 (95% CI, 0.44-0.79), as was overall survival, at a hazard ratio of 0.56 (95% CI, 0.42-0.75).

There was no significant difference in rwPFS and overall survival between vaccinated and unvaccinated patients among those with NSCLC, but significant differences were seen in those with cutaneous malignant melanoma, at hazard ratios of 0.58 (95% CI, 0.36-0.96) and 0.58 (95% CI, 0.36-0.96), respectively.

Restricting the analysis to immune checkpoint inhibitor monotherapy indicated that vaccinated patients had significantly longer rwPFS and overall survival than unvaccinated patients, at hazard ratios of 0.58 (95% CI, 0.43-0.79) and 0.50 (95% CI, 0.38-0.76), respectively.

Finally, the team found that there were no significant differences in the rates of any grade IRAEs between vaccinated and unvaccinated patients, at 48.4% vs 51.2% (P = .455), or in rates of multiple IRAEs, at 15.1% vs 19.2% (P = .297). The therapeutic management and outcomes of IRAEs were also comparable.

No funding or relevant financial relationships were declared.

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

Patients with advanced cancer treated with immune checkpoint inhibitors appear to have a survival benefit if they receive influenza vaccination, a new retrospective analysis found. The results also suggest no increase in the risk for immune-related adverse events (IRAEs) in these patients and that the improvement in survival outcomes may be stronger among those with cutaneous malignant melanoma.

“Our findings align with a growing body of evidence, mainly from retrospective studies, that suggest a potential association between influenza vaccination during immune checkpoint inhibitor treatment and improved survival among patients with cancer,” wrote senior author Antonis Valachis, MD, PhD, and colleagues in an article published in JCO Clinical Practice on February 9. “An additional clinically relevant observation is that the association between influenza vaccination and survival may vary by tumor type.”

The new research supports “current recommendations to offer influenza vaccination to all patients undergoing cancer therapy, including those receiving the drugs,” Valachis, of the Department of Oncology, Örebro University in Örebro, Sweden, and his coauthors wrote.

“What we observed is that influenza vaccination is safe for patients under immunotherapy treatment,” Valachis told Medscape Medical News. But “whether influenza vaccination can be used to boost immunotherapy effectiveness should be tested in a study with a different design,” such as a prospective interventional trial.

Discussing potential explanations for why influenza vaccination could affect immunotherapy outcomes without affecting rates of IRAEs, Valachis said that this “cannot be answered within the constraints of our study design, since all patients were treated with immunotherapy.”

It may nevertheless be hypothesized that “immune activation triggered by vaccination preferentially stimulates immune mechanisms that enhance immunotherapy efficacy, while sparing those that contribute to IRAEs.”

Steady Was 'Relatively Modestly Sized'

Question marks were raised over the study itself and, as a result, its findings.

Justin Jee, MD, PhD, a thoracic medical oncologist at Memorial Sloan Kettering Cancer Center, New York City, told Medscape Medical News that there are “a lot of challenges when looking at retrospective data.”

“The authors did a very reasonable job of trying to control for confounders and certain time dependent issues, like immortality bias,” he said. “That said, it’s a relatively modestly sized retrospective study for looking at something that has enormous potential for confounding bias that really can’t be captured with any standard statistical method.”

Jee pointed to factors such as providers potentially being more likely to refer people for vaccination if they’re healthier “vs if the patient is in hospice care,” or individuals simply not getting vaccinated because it is not uppermost in their mind.

“Those things are very, very difficult to control for.”

Jee also said he believes the benefit with influenza vaccination being stronger in cutaneous malignant melanoma could be a study artifact, while the lack of difference in rates of IRAEs could be the result of selection bias, but “it’s just impossible to say with a study like this.”

“I’ve seen several studies looking at both COVID and flu vaccines and whether or not they improve immune checkpoint blockade efficacy,” he added, explaining that “some of them say COVID vaccine good, flu vaccine not as good; others say both flu and COVID vaccines good; others say flu vaccine good, COVID vaccine not as good.”

All Patients With Cancer Should Be Vaccinated

What is clear is that “patients with cancer are [at] especially high risk of developing complications from viral illnesses, including flu, including COVID, and vaccines are a very important part of reducing morbidity, mortality, and spread,” Jee said. The “big picture” is that everyone should get the influenza vaccine, especially patients with cancer, “so in that sense I agree with that part of the conclusion of the paper” and that’s “an important message.”

Mini Kamboj, MD, chief medical epidemiologist at Memorial Sloan Kettering Cancer Center, agreed, saying that the results are “consistent with other research showing that vaccines are safe and beneficial for patients on checkpoint inhibitors.”

“While vaccinated patients with melanoma showed the greatest survival benefit, the authors note small sample size and unrecognized differences between the groups as a potential explanation for their findings. This does not change vaccine recommendations as evidence already supports flu vaccine safety and effectiveness in people with lung cancer on checkpoint inhibitors.”

Nearly 600 Patients With Advanced Cancer

The researchers performed a retrospective cohort study of patients from three regions in Sweden who had advanced solid tumors and were treated with PD-1 or PD-L1 inhibitor monotherapy, or PD-1 combination therapy with a cytotoxic T-lymphocyte-associated protein 4 inhibitor, between January 1, 2016, until December 31, 2021. Treatment was given either routinely or as part of a clinical trial.

Electronic medical records were examined to gather data on a range of variables, including age at diagnosis, sex, Charlson Comorbidity Index, type of cancer, primary treatment at diagnosis, number of previous lines of treatment, best treatment response, IRAEs, influenza vaccination status, and date and cause of death.

In all, 587 patients were treated with immune checkpoint inhibition over the study period. They had a median age of 66 years, and 58.1% were men. The most common malignancies were nonsmall cell lung cancer (NSCLC), cutaneous malignant melanoma (32.5%), and renal cell carcinoma (14.7%).

The most commonly used immune checkpoint inhibitor was nivolumab, which was administered to 47.9% of patients, followed by pembrolizumab (34.6%), atezolizumab (9.4%), and nivolumab plus ipilimumab (6.8%).

Only Patients With Malignant Melanoma Benefit

Over the study period, 17.7% of patients underwent influenza vaccination, at a median time between initiation of immune checkpoint inhibition and vaccination of 2 months. Ninety per cent of patients received the vaccine within 9 months of starting treatment.

Time-dependent Cox regression analysis revealed that real-world progression-free survival (rwPFS) was significantly longer with vaccinated patients than unvaccinated patients at a hazard ratio of 0.59 (95% CI, 0.44-0.79), as was overall survival, at a hazard ratio of 0.56 (95% CI, 0.42-0.75).

There was no significant difference in rwPFS and overall survival between vaccinated and unvaccinated patients among those with NSCLC, but significant differences were seen in those with cutaneous malignant melanoma, at hazard ratios of 0.58 (95% CI, 0.36-0.96) and 0.58 (95% CI, 0.36-0.96), respectively.

Restricting the analysis to immune checkpoint inhibitor monotherapy indicated that vaccinated patients had significantly longer rwPFS and overall survival than unvaccinated patients, at hazard ratios of 0.58 (95% CI, 0.43-0.79) and 0.50 (95% CI, 0.38-0.76), respectively.

Finally, the team found that there were no significant differences in the rates of any grade IRAEs between vaccinated and unvaccinated patients, at 48.4% vs 51.2% (P = .455), or in rates of multiple IRAEs, at 15.1% vs 19.2% (P = .297). The therapeutic management and outcomes of IRAEs were also comparable.

No funding or relevant financial relationships were declared.

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

US service members and veterans were less likely to die than the general population from most causes of death over a 17-year period, a population-based, prospective analysis found. But there was a glaring exception: suicide by firearm.

Among 201,618 subjects tracked from 2001 to 2018 by the Millennium Cohort Study, the overall death rate was less than half that of a comparable group of US adults (standardized mortality ratios [SMR], 0.44), reported Edward J. Boyko, MD, MPH, staff physician with the Veterans Affairs (VA) Puget Sound Health Care System and professor of medicine at the University of Washington, Seattle, and colleagues in BMC Public Health. However, suicides by firearm—while rare—were more common overall (SMR, 1.42), among military men only (SMR, 1.33), and among military women only (SMR, 2.83) than civilians. 

The findings about the overall death rate may reflect the better health of those who join the military and have access to health care during and after service, Boyko told Federal Practitioner. The suicide data may reflect higher access to firearms, he said, although “more research is needed to identify what types of military exposures or physical and mental health predictors are associated with increased mortality risk due to suicide.”

The ongoing Millennium Cohort Study began in 2001 to track the health of military personnel over time. The study has spawned > 180 reports “used to inform and guide policy, guidelines, and health promotion efforts within the military and VA,” Boyko said. “As the Millennium Cohort Study approaches its 25-year anniversary, it seemed like an ideal time to assess mortality, especially cause-specific mortality, as a way to measure the impact of military service on long-term health.”

The analysis tracks 4 panels of subjects enrolled at various times between 2001 and 2013. Of the 201,619 participants, 3018 (1.5%) died by 2018. Of the 198,01 nondeceased participants, 69.2% were male; 8.1% were born before 1960, 16.1% were born from 1960 to 1969, 24.4% were born from 1970 to 1979, and 51.5% were born in or after 1980. The racial/ethnic makeup was 72.7% non-Hispanic White, 12.2% non-Hispanic Black, 7.9% Hispanic, and 7.1% other. Two-thirds (66.4%) were active duty, and 33.6% were in the Reserve or National Guard.

Of the 3018 deceased participants, 81.2% were male. In terms of birth year, 32.4% were born before 1960, 22.1% were born from 1960 to 1969, 18.2% were born from 1970 to 1979, and 27.3% were born in or after 1980. The racial/ethnic makeup was 77.7% non-Hispanic White, 11.9% non-Hispanic Black, 5.5% Hispanic, and 4.9% other. About half (51.0%) were active duty, and 49.0% were in the Reserve or National Guard.

Most deaths were due to natural causes (57.0%), followed by accident (20.1%), suicide (17.1%), operations of war (3.0%), homicide (2.1%), and other causes (1.2%). The new report noted that the Millennium Cohort Study and other research have identified a “healthy soldier effect, in which military populations tend to be healthier than the general US population.”

Boyko explained that “the fitness requirements for joining the military may favor the selection of healthier individuals from the general population. Another benefit of military service is free access to health care, especially among those on active duty, as well as eligibility for VA health care and other benefits after leaving service. This would allow for greater access to preventive care and treatments, as well as routine screening for health conditions such as cancer, diabetes, or cardiovascular disease.”

Overall suicide rates were higher among female subjects than among civilians (SMR, 1.65), but no statistically significant difference was seen in men (SMR, 0.96) or across all participants (SMR, 1.03). Regarding the large gaps in firearm suicide rates in military subjects vs civilians, Boyko said, “accessibility and familiarity with firearms, a highly lethal means of suicide, may be driving the elevated risk of suicide by firearms … prior research has found that unsecure firearms storage—such as unlocked, loaded firearms—increases the risk of suicide by firearms.”

Rachel Sayko Adams, PhD, MPH, a research associate professor with the Department of Health Law, Policy and Management at Boston University School of Public Health, is familiar with the study findings. Adams, a principal investigator at the VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, told Federal Practitioner that “efforts to further develop suicide prevention programs that consider the unique needs and preferences of female service members and veterans are critical to prevent future suicide mortality in this population.”

Adams added: “Just because service members and veterans have a lower all-cause mortality rate compared to the general US population, we should not assume that they are universally low risk or that we can reduce our public health prevention efforts targeting this population.”

Boyko highlighted KeepItSecure.net, which “helps veterans and service members protect themselves and their families by making it easier to store firearms securely during stressful or high-risk periods.” The site offers practical, judgment-free guidance with powerful storytelling and public outreach, with clear, actionable steps—such as using a cable gun lock or lockbox—to lower suicide risk long before a crisis occurs. The VA, Boyko said, provides free cable gun locks nationwide.

The Millennium Cohort Study is funded by the Department of Veterans Affairs and Department of Defense Military Operational Medicine Research Program and Defense Health Program. The report authors and Adams have no disclosures. 

US service members and veterans were less likely to die than the general population from most causes of death over a 17-year period, a population-based, prospective analysis found. But there was a glaring exception: suicide by firearm.

Among 201,618 subjects tracked from 2001 to 2018 by the Millennium Cohort Study, the overall death rate was less than half that of a comparable group of US adults (standardized mortality ratios [SMR], 0.44), reported Edward J. Boyko, MD, MPH, staff physician with the Veterans Affairs (VA) Puget Sound Health Care System and professor of medicine at the University of Washington, Seattle, and colleagues in BMC Public Health. However, suicides by firearm—while rare—were more common overall (SMR, 1.42), among military men only (SMR, 1.33), and among military women only (SMR, 2.83) than civilians. 

The findings about the overall death rate may reflect the better health of those who join the military and have access to health care during and after service, Boyko told Federal Practitioner. The suicide data may reflect higher access to firearms, he said, although “more research is needed to identify what types of military exposures or physical and mental health predictors are associated with increased mortality risk due to suicide.”

The ongoing Millennium Cohort Study began in 2001 to track the health of military personnel over time. The study has spawned > 180 reports “used to inform and guide policy, guidelines, and health promotion efforts within the military and VA,” Boyko said. “As the Millennium Cohort Study approaches its 25-year anniversary, it seemed like an ideal time to assess mortality, especially cause-specific mortality, as a way to measure the impact of military service on long-term health.”

The analysis tracks 4 panels of subjects enrolled at various times between 2001 and 2013. Of the 201,619 participants, 3018 (1.5%) died by 2018. Of the 198,01 nondeceased participants, 69.2% were male; 8.1% were born before 1960, 16.1% were born from 1960 to 1969, 24.4% were born from 1970 to 1979, and 51.5% were born in or after 1980. The racial/ethnic makeup was 72.7% non-Hispanic White, 12.2% non-Hispanic Black, 7.9% Hispanic, and 7.1% other. Two-thirds (66.4%) were active duty, and 33.6% were in the Reserve or National Guard.

Of the 3018 deceased participants, 81.2% were male. In terms of birth year, 32.4% were born before 1960, 22.1% were born from 1960 to 1969, 18.2% were born from 1970 to 1979, and 27.3% were born in or after 1980. The racial/ethnic makeup was 77.7% non-Hispanic White, 11.9% non-Hispanic Black, 5.5% Hispanic, and 4.9% other. About half (51.0%) were active duty, and 49.0% were in the Reserve or National Guard.

Most deaths were due to natural causes (57.0%), followed by accident (20.1%), suicide (17.1%), operations of war (3.0%), homicide (2.1%), and other causes (1.2%). The new report noted that the Millennium Cohort Study and other research have identified a “healthy soldier effect, in which military populations tend to be healthier than the general US population.”

Boyko explained that “the fitness requirements for joining the military may favor the selection of healthier individuals from the general population. Another benefit of military service is free access to health care, especially among those on active duty, as well as eligibility for VA health care and other benefits after leaving service. This would allow for greater access to preventive care and treatments, as well as routine screening for health conditions such as cancer, diabetes, or cardiovascular disease.”

Overall suicide rates were higher among female subjects than among civilians (SMR, 1.65), but no statistically significant difference was seen in men (SMR, 0.96) or across all participants (SMR, 1.03). Regarding the large gaps in firearm suicide rates in military subjects vs civilians, Boyko said, “accessibility and familiarity with firearms, a highly lethal means of suicide, may be driving the elevated risk of suicide by firearms … prior research has found that unsecure firearms storage—such as unlocked, loaded firearms—increases the risk of suicide by firearms.”

Rachel Sayko Adams, PhD, MPH, a research associate professor with the Department of Health Law, Policy and Management at Boston University School of Public Health, is familiar with the study findings. Adams, a principal investigator at the VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, told Federal Practitioner that “efforts to further develop suicide prevention programs that consider the unique needs and preferences of female service members and veterans are critical to prevent future suicide mortality in this population.”

Adams added: “Just because service members and veterans have a lower all-cause mortality rate compared to the general US population, we should not assume that they are universally low risk or that we can reduce our public health prevention efforts targeting this population.”

Boyko highlighted KeepItSecure.net, which “helps veterans and service members protect themselves and their families by making it easier to store firearms securely during stressful or high-risk periods.” The site offers practical, judgment-free guidance with powerful storytelling and public outreach, with clear, actionable steps—such as using a cable gun lock or lockbox—to lower suicide risk long before a crisis occurs. The VA, Boyko said, provides free cable gun locks nationwide.

The Millennium Cohort Study is funded by the Department of Veterans Affairs and Department of Defense Military Operational Medicine Research Program and Defense Health Program. The report authors and Adams have no disclosures. 

US service members and veterans were less likely to die than the general population from most causes of death over a 17-year period, a population-based, prospective analysis found. But there was a glaring exception: suicide by firearm.

Among 201,618 subjects tracked from 2001 to 2018 by the Millennium Cohort Study, the overall death rate was less than half that of a comparable group of US adults (standardized mortality ratios [SMR], 0.44), reported Edward J. Boyko, MD, MPH, staff physician with the Veterans Affairs (VA) Puget Sound Health Care System and professor of medicine at the University of Washington, Seattle, and colleagues in BMC Public Health. However, suicides by firearm—while rare—were more common overall (SMR, 1.42), among military men only (SMR, 1.33), and among military women only (SMR, 2.83) than civilians. 

The findings about the overall death rate may reflect the better health of those who join the military and have access to health care during and after service, Boyko told Federal Practitioner. The suicide data may reflect higher access to firearms, he said, although “more research is needed to identify what types of military exposures or physical and mental health predictors are associated with increased mortality risk due to suicide.”

The ongoing Millennium Cohort Study began in 2001 to track the health of military personnel over time. The study has spawned > 180 reports “used to inform and guide policy, guidelines, and health promotion efforts within the military and VA,” Boyko said. “As the Millennium Cohort Study approaches its 25-year anniversary, it seemed like an ideal time to assess mortality, especially cause-specific mortality, as a way to measure the impact of military service on long-term health.”

The analysis tracks 4 panels of subjects enrolled at various times between 2001 and 2013. Of the 201,619 participants, 3018 (1.5%) died by 2018. Of the 198,01 nondeceased participants, 69.2% were male; 8.1% were born before 1960, 16.1% were born from 1960 to 1969, 24.4% were born from 1970 to 1979, and 51.5% were born in or after 1980. The racial/ethnic makeup was 72.7% non-Hispanic White, 12.2% non-Hispanic Black, 7.9% Hispanic, and 7.1% other. Two-thirds (66.4%) were active duty, and 33.6% were in the Reserve or National Guard.

Of the 3018 deceased participants, 81.2% were male. In terms of birth year, 32.4% were born before 1960, 22.1% were born from 1960 to 1969, 18.2% were born from 1970 to 1979, and 27.3% were born in or after 1980. The racial/ethnic makeup was 77.7% non-Hispanic White, 11.9% non-Hispanic Black, 5.5% Hispanic, and 4.9% other. About half (51.0%) were active duty, and 49.0% were in the Reserve or National Guard.

Most deaths were due to natural causes (57.0%), followed by accident (20.1%), suicide (17.1%), operations of war (3.0%), homicide (2.1%), and other causes (1.2%). The new report noted that the Millennium Cohort Study and other research have identified a “healthy soldier effect, in which military populations tend to be healthier than the general US population.”

Boyko explained that “the fitness requirements for joining the military may favor the selection of healthier individuals from the general population. Another benefit of military service is free access to health care, especially among those on active duty, as well as eligibility for VA health care and other benefits after leaving service. This would allow for greater access to preventive care and treatments, as well as routine screening for health conditions such as cancer, diabetes, or cardiovascular disease.”

Overall suicide rates were higher among female subjects than among civilians (SMR, 1.65), but no statistically significant difference was seen in men (SMR, 0.96) or across all participants (SMR, 1.03). Regarding the large gaps in firearm suicide rates in military subjects vs civilians, Boyko said, “accessibility and familiarity with firearms, a highly lethal means of suicide, may be driving the elevated risk of suicide by firearms … prior research has found that unsecure firearms storage—such as unlocked, loaded firearms—increases the risk of suicide by firearms.”

Rachel Sayko Adams, PhD, MPH, a research associate professor with the Department of Health Law, Policy and Management at Boston University School of Public Health, is familiar with the study findings. Adams, a principal investigator at the VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, told Federal Practitioner that “efforts to further develop suicide prevention programs that consider the unique needs and preferences of female service members and veterans are critical to prevent future suicide mortality in this population.”

Adams added: “Just because service members and veterans have a lower all-cause mortality rate compared to the general US population, we should not assume that they are universally low risk or that we can reduce our public health prevention efforts targeting this population.”

Boyko highlighted KeepItSecure.net, which “helps veterans and service members protect themselves and their families by making it easier to store firearms securely during stressful or high-risk periods.” The site offers practical, judgment-free guidance with powerful storytelling and public outreach, with clear, actionable steps—such as using a cable gun lock or lockbox—to lower suicide risk long before a crisis occurs. The VA, Boyko said, provides free cable gun locks nationwide.

The Millennium Cohort Study is funded by the Department of Veterans Affairs and Department of Defense Military Operational Medicine Research Program and Defense Health Program. The report authors and Adams have no disclosures. 

One of the most common questions my patients ask is, “What diet can help me beat this cancer?” It is a profoundly important question that is worthy of our efforts to answer. In this brief essay, I will take a deep dive into this question in depth and explore the broader clinical and scientific themes it brings into play.

Low-Hanging Fruit: Nutrition Science

A cancer diagnosis can be a deeply disempowering experience. Although I have not lived with cancer myself, I have seen this play out repeatedly over the past 5 years in my role as an oncologist treating patients with hematologic malignancies.

Our diet is an important part of our personal identity, culturally and spiritually. If lifestyle changes, such as a modified diet or more exercise, can contribute to cancer treatment, it may help us regain a sense of control over our lives, one that cancer so often cruelly strips away. I hypothesize that, among other factors, this is why diet is so important to our patients.

Another factor is exposure to a compelling diet-cancer narrative. Nearly every day, a media headline appears claiming that eating a particular food, or drinking coffee, can either increase or decrease your risk for a certain disease.

These claims, however, are often based on studies of large observational datasets where individuals fill out surveys about their dietary habits and are subsequently assessed for disease outcomes. In these studies, people aren’t asked to eat a particular diet; instead, their dietary habits are analyzed by researchers who have endless permutations to explore. This, in a nutshell, is the field of nutritional epidemiology.

In my opinion, nutritional epidemiology represents the collision of the well-intentioned effort to answer clinically meaningful questions with the ease — and near-infinite permutations — of dietary questions that can be asked from an increasingly larger number of different datasets.

Now, factor in the never-ending appetite (pun intended) of journalism and the public’s desire for dietary studies, and you create the perfect storm of incentives that drives a flood of low-quality nutritional science. These studies are highly malleable to analytical choices and can essentially produce results consistent with your prior beliefs, regardless of the philosophical inclination you have (pro keto-diet, pro-vegan, etc.). I love quoting this study to my trainees that, depending on what variables are included and how the analysis is conducted, the same dataset could be used to show that red meat either increases, decreases, or has no effect on all-cause mortality. Unfortunately, much of the evidence base for diet in cancer comes from similarly confounded, low-quality studies.

Diet and Cancer

So, what do randomized trials show for diet and cancer?

The highest-quality evidence is generated from randomized controlled trials. One of their key advantages is the ability to control both measured and unmeasured confounders.

Unfortunately, the evidence supporting diet as an anticancer modality in randomized trials in patients with cancer is bleak. We did a systematic review of all randomized trials of dietary intervention ever done in patients with cancer. Most of the trials measured outcomes such as feasibility (often small pilot studies that measure variables such as weight changes or lab values). The trials that measure clinical endpoints, such as survival, were largely negative and demonstrated no meaningful effect of diet on outcomes. Take trials exploring whether a Mediterranean diet helps prevent breast cancer recurrence, or whether a diet rich in fruits and vegetables improves prostate cancer outcomes. Although these diets may offer benefits, these studies found that specific diets did not change the natural history of cancer.

Myeloma and Diet

In my specialty, multiple myeloma, I am thankful that some trials are beginning to shed light on whether diet influences cancer outcomes.

One study, which was recently published in Cancer Discovery, explored whether a high-fiber, plant-based diet could potentially slow or delay progression from myeloma precursor conditions toward full-blown multiple myeloma. The trial enrolled 23 participants, with the primary endpoints of dietary adherence and changes to BMI. Measures of progression to multiple myeloma were exploratory at best. Yet, the media coverage, as well as the majority of the discussion and results sections of this study manuscript, claimed that the diet changes can prevent progression to myeloma.

However, the study design and conclusions were flawed. The paper focused on two patients who had some improvement in disease trajectory, while descriptions of patients who had an increase in their bone marrow plasma cell percentage were relegated to the supplemental section.

As a primary investigator of a trial in smoldering myeloma where we use advanced imaging as an alternative to pharmacologic treatment, I frequently see myeloma markers fluctuate and often decrease. I attribute these changes to random variation, or possibly regression to the mean, rather than the effect of any intervention.

Future randomized studies by this group used primary endpoints of stool butyrate level and implement dietary interventions for a limited period— 2 weeks in one study and 12 weeks in another — to again assess the impact of a high-fiber, plant-based diet on progression to myeloma. Although there are no data yet, the limited timeframes in these studies severely limits generalizability for outcomes that would truly matter, such as cancer control and longevity. There is also no evidence that changes in stool butyrate levels influence patient outcomes.

High-quality science — whether it is evaluating diet or other interventions—requires high-quality data, effort, funding, and time. It is not impossible.

We can draw inspiration from the CHALLENGE trial. This large, randomized trial, which took over a decade to complete, assessed the benefit of a structured exercise program in the adjuvant setting for colon cancer. The endpoint of this study was disease-free survival, and the intervention was deployed over a much longer period: 3 years, as opposed to a 2-week intervention. This trial took years from inception to completion, but it yielded a conclusive result and will probably lead to more dedicated efforts to facilitate exercise programs for patients with cancer.

Our patients deserve the same effort as the CHALLENGE trial to answer their important dietary questions. Until such trials are completed, we must acknowledge, with humility, that despite the common sense and feel-good factor that many diets offer us, their impact on cancer remains uncertain.

Conversely, we must recognize that even if diet does not cure or alter the course of a certain cancer, it can still impact quality of life, treatment tolerance, and other supportive care outcomes, making it an important factor in patient care.

This is what I tell my patients that it is unlikely any one diet will change the trajectory of your cancer. Focus on eating healthy, and remember that most things in moderation are fine. Your diet remains an important risk factor and determinant for health outcomes beyond cancer. Eat what makes you happy. You are going through a tough time, and this is not the moment to impose stringent restrictions on yourself.

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

One of the most common questions my patients ask is, “What diet can help me beat this cancer?” It is a profoundly important question that is worthy of our efforts to answer. In this brief essay, I will take a deep dive into this question in depth and explore the broader clinical and scientific themes it brings into play.

Low-Hanging Fruit: Nutrition Science

A cancer diagnosis can be a deeply disempowering experience. Although I have not lived with cancer myself, I have seen this play out repeatedly over the past 5 years in my role as an oncologist treating patients with hematologic malignancies.

Our diet is an important part of our personal identity, culturally and spiritually. If lifestyle changes, such as a modified diet or more exercise, can contribute to cancer treatment, it may help us regain a sense of control over our lives, one that cancer so often cruelly strips away. I hypothesize that, among other factors, this is why diet is so important to our patients.

Another factor is exposure to a compelling diet-cancer narrative. Nearly every day, a media headline appears claiming that eating a particular food, or drinking coffee, can either increase or decrease your risk for a certain disease.

These claims, however, are often based on studies of large observational datasets where individuals fill out surveys about their dietary habits and are subsequently assessed for disease outcomes. In these studies, people aren’t asked to eat a particular diet; instead, their dietary habits are analyzed by researchers who have endless permutations to explore. This, in a nutshell, is the field of nutritional epidemiology.

In my opinion, nutritional epidemiology represents the collision of the well-intentioned effort to answer clinically meaningful questions with the ease — and near-infinite permutations — of dietary questions that can be asked from an increasingly larger number of different datasets.

Now, factor in the never-ending appetite (pun intended) of journalism and the public’s desire for dietary studies, and you create the perfect storm of incentives that drives a flood of low-quality nutritional science. These studies are highly malleable to analytical choices and can essentially produce results consistent with your prior beliefs, regardless of the philosophical inclination you have (pro keto-diet, pro-vegan, etc.). I love quoting this study to my trainees that, depending on what variables are included and how the analysis is conducted, the same dataset could be used to show that red meat either increases, decreases, or has no effect on all-cause mortality. Unfortunately, much of the evidence base for diet in cancer comes from similarly confounded, low-quality studies.

Diet and Cancer

So, what do randomized trials show for diet and cancer?

The highest-quality evidence is generated from randomized controlled trials. One of their key advantages is the ability to control both measured and unmeasured confounders.

Unfortunately, the evidence supporting diet as an anticancer modality in randomized trials in patients with cancer is bleak. We did a systematic review of all randomized trials of dietary intervention ever done in patients with cancer. Most of the trials measured outcomes such as feasibility (often small pilot studies that measure variables such as weight changes or lab values). The trials that measure clinical endpoints, such as survival, were largely negative and demonstrated no meaningful effect of diet on outcomes. Take trials exploring whether a Mediterranean diet helps prevent breast cancer recurrence, or whether a diet rich in fruits and vegetables improves prostate cancer outcomes. Although these diets may offer benefits, these studies found that specific diets did not change the natural history of cancer.

Myeloma and Diet

In my specialty, multiple myeloma, I am thankful that some trials are beginning to shed light on whether diet influences cancer outcomes.

One study, which was recently published in Cancer Discovery, explored whether a high-fiber, plant-based diet could potentially slow or delay progression from myeloma precursor conditions toward full-blown multiple myeloma. The trial enrolled 23 participants, with the primary endpoints of dietary adherence and changes to BMI. Measures of progression to multiple myeloma were exploratory at best. Yet, the media coverage, as well as the majority of the discussion and results sections of this study manuscript, claimed that the diet changes can prevent progression to myeloma.

However, the study design and conclusions were flawed. The paper focused on two patients who had some improvement in disease trajectory, while descriptions of patients who had an increase in their bone marrow plasma cell percentage were relegated to the supplemental section.

As a primary investigator of a trial in smoldering myeloma where we use advanced imaging as an alternative to pharmacologic treatment, I frequently see myeloma markers fluctuate and often decrease. I attribute these changes to random variation, or possibly regression to the mean, rather than the effect of any intervention.

Future randomized studies by this group used primary endpoints of stool butyrate level and implement dietary interventions for a limited period— 2 weeks in one study and 12 weeks in another — to again assess the impact of a high-fiber, plant-based diet on progression to myeloma. Although there are no data yet, the limited timeframes in these studies severely limits generalizability for outcomes that would truly matter, such as cancer control and longevity. There is also no evidence that changes in stool butyrate levels influence patient outcomes.

High-quality science — whether it is evaluating diet or other interventions—requires high-quality data, effort, funding, and time. It is not impossible.

We can draw inspiration from the CHALLENGE trial. This large, randomized trial, which took over a decade to complete, assessed the benefit of a structured exercise program in the adjuvant setting for colon cancer. The endpoint of this study was disease-free survival, and the intervention was deployed over a much longer period: 3 years, as opposed to a 2-week intervention. This trial took years from inception to completion, but it yielded a conclusive result and will probably lead to more dedicated efforts to facilitate exercise programs for patients with cancer.

Our patients deserve the same effort as the CHALLENGE trial to answer their important dietary questions. Until such trials are completed, we must acknowledge, with humility, that despite the common sense and feel-good factor that many diets offer us, their impact on cancer remains uncertain.

Conversely, we must recognize that even if diet does not cure or alter the course of a certain cancer, it can still impact quality of life, treatment tolerance, and other supportive care outcomes, making it an important factor in patient care.

This is what I tell my patients that it is unlikely any one diet will change the trajectory of your cancer. Focus on eating healthy, and remember that most things in moderation are fine. Your diet remains an important risk factor and determinant for health outcomes beyond cancer. Eat what makes you happy. You are going through a tough time, and this is not the moment to impose stringent restrictions on yourself.

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

One of the most common questions my patients ask is, “What diet can help me beat this cancer?” It is a profoundly important question that is worthy of our efforts to answer. In this brief essay, I will take a deep dive into this question in depth and explore the broader clinical and scientific themes it brings into play.

Low-Hanging Fruit: Nutrition Science

A cancer diagnosis can be a deeply disempowering experience. Although I have not lived with cancer myself, I have seen this play out repeatedly over the past 5 years in my role as an oncologist treating patients with hematologic malignancies.

Our diet is an important part of our personal identity, culturally and spiritually. If lifestyle changes, such as a modified diet or more exercise, can contribute to cancer treatment, it may help us regain a sense of control over our lives, one that cancer so often cruelly strips away. I hypothesize that, among other factors, this is why diet is so important to our patients.

Another factor is exposure to a compelling diet-cancer narrative. Nearly every day, a media headline appears claiming that eating a particular food, or drinking coffee, can either increase or decrease your risk for a certain disease.

These claims, however, are often based on studies of large observational datasets where individuals fill out surveys about their dietary habits and are subsequently assessed for disease outcomes. In these studies, people aren’t asked to eat a particular diet; instead, their dietary habits are analyzed by researchers who have endless permutations to explore. This, in a nutshell, is the field of nutritional epidemiology.

In my opinion, nutritional epidemiology represents the collision of the well-intentioned effort to answer clinically meaningful questions with the ease — and near-infinite permutations — of dietary questions that can be asked from an increasingly larger number of different datasets.

Now, factor in the never-ending appetite (pun intended) of journalism and the public’s desire for dietary studies, and you create the perfect storm of incentives that drives a flood of low-quality nutritional science. These studies are highly malleable to analytical choices and can essentially produce results consistent with your prior beliefs, regardless of the philosophical inclination you have (pro keto-diet, pro-vegan, etc.). I love quoting this study to my trainees that, depending on what variables are included and how the analysis is conducted, the same dataset could be used to show that red meat either increases, decreases, or has no effect on all-cause mortality. Unfortunately, much of the evidence base for diet in cancer comes from similarly confounded, low-quality studies.

Diet and Cancer

So, what do randomized trials show for diet and cancer?

The highest-quality evidence is generated from randomized controlled trials. One of their key advantages is the ability to control both measured and unmeasured confounders.

Unfortunately, the evidence supporting diet as an anticancer modality in randomized trials in patients with cancer is bleak. We did a systematic review of all randomized trials of dietary intervention ever done in patients with cancer. Most of the trials measured outcomes such as feasibility (often small pilot studies that measure variables such as weight changes or lab values). The trials that measure clinical endpoints, such as survival, were largely negative and demonstrated no meaningful effect of diet on outcomes. Take trials exploring whether a Mediterranean diet helps prevent breast cancer recurrence, or whether a diet rich in fruits and vegetables improves prostate cancer outcomes. Although these diets may offer benefits, these studies found that specific diets did not change the natural history of cancer.

Myeloma and Diet

In my specialty, multiple myeloma, I am thankful that some trials are beginning to shed light on whether diet influences cancer outcomes.

One study, which was recently published in Cancer Discovery, explored whether a high-fiber, plant-based diet could potentially slow or delay progression from myeloma precursor conditions toward full-blown multiple myeloma. The trial enrolled 23 participants, with the primary endpoints of dietary adherence and changes to BMI. Measures of progression to multiple myeloma were exploratory at best. Yet, the media coverage, as well as the majority of the discussion and results sections of this study manuscript, claimed that the diet changes can prevent progression to myeloma.

However, the study design and conclusions were flawed. The paper focused on two patients who had some improvement in disease trajectory, while descriptions of patients who had an increase in their bone marrow plasma cell percentage were relegated to the supplemental section.

As a primary investigator of a trial in smoldering myeloma where we use advanced imaging as an alternative to pharmacologic treatment, I frequently see myeloma markers fluctuate and often decrease. I attribute these changes to random variation, or possibly regression to the mean, rather than the effect of any intervention.

Future randomized studies by this group used primary endpoints of stool butyrate level and implement dietary interventions for a limited period— 2 weeks in one study and 12 weeks in another — to again assess the impact of a high-fiber, plant-based diet on progression to myeloma. Although there are no data yet, the limited timeframes in these studies severely limits generalizability for outcomes that would truly matter, such as cancer control and longevity. There is also no evidence that changes in stool butyrate levels influence patient outcomes.

High-quality science — whether it is evaluating diet or other interventions—requires high-quality data, effort, funding, and time. It is not impossible.

We can draw inspiration from the CHALLENGE trial. This large, randomized trial, which took over a decade to complete, assessed the benefit of a structured exercise program in the adjuvant setting for colon cancer. The endpoint of this study was disease-free survival, and the intervention was deployed over a much longer period: 3 years, as opposed to a 2-week intervention. This trial took years from inception to completion, but it yielded a conclusive result and will probably lead to more dedicated efforts to facilitate exercise programs for patients with cancer.

Our patients deserve the same effort as the CHALLENGE trial to answer their important dietary questions. Until such trials are completed, we must acknowledge, with humility, that despite the common sense and feel-good factor that many diets offer us, their impact on cancer remains uncertain.

Conversely, we must recognize that even if diet does not cure or alter the course of a certain cancer, it can still impact quality of life, treatment tolerance, and other supportive care outcomes, making it an important factor in patient care.

This is what I tell my patients that it is unlikely any one diet will change the trajectory of your cancer. Focus on eating healthy, and remember that most things in moderation are fine. Your diet remains an important risk factor and determinant for health outcomes beyond cancer. Eat what makes you happy. You are going through a tough time, and this is not the moment to impose stringent restrictions on yourself.

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