Mixed Topics

Click here for the Thursday issue of the SHM Converge Daily News newsletter.

Click here for the Thursday issue of the SHM Converge Daily News newsletter.

Click here for the Thursday issue of the SHM Converge Daily News newsletter.

Click here for the Wednesday issue of the SHM Converge Daily News newsletter.

Click here for the Wednesday issue of the SHM Converge Daily News newsletter.

Click here for the Wednesday issue of the SHM Converge Daily News newsletter.

To the Editor:

Levamisole is a veterinary anthelmintic drug with immunomodulating properties that was once approved by the US Food and Drug Administration for the treatment of various conditions, including autoimmune diseases, cancer, pediatric kidney disease, and chronic infections.^1-4 Levamisole was banned in 2000 after reports of associated agranulocytosis and a characteristic painful purpuric vasculitis.^4,5 Despite the ban, its use persists due to its increasing incorporation as an adulterant in cocaine, presumably for its dopaminergic properties that potentiate psychotropic effects.⁶ In 2009, the Drug Enforcement Administration reported that 69% of seized cocaine in the United States contains this chemical, with an average concentration of 10%.⁵ Levamisole-induced vasculopathy (LIV) typically resolves following the cessation of cocaine without further treatment necessary. We present a fatal case of LIV to emphasize that early recognition and discontinuation of the offending agent could be lifesaving.

A 40-year-old woman with a history of cocaine abuse was admitted with tender, reticular, purpuric, and erythematous patches and plaques on the lower extremities with areas of necrosis (Figure 1). The lesions had been present intermittently for 6 months. She tried topical mupirocin and oral amoxicillin clavulanate without improvement. She also described polyarthralgia in the hands, but the remainder of the review of symptoms and physical examination was negative.

The pathogenesis of LIV is not completely understood, but it is thought to be an immune complex–mediated process based on immunofluorescence studies in the skin.^13,14 Classic pathologic findings include multiple fibrin thrombi within small vessels in the superficial and deep dermis, leukocytoclastic vasculitis of small vessels consisting of fibrinoid necrosis of the vessel wall, extravasated erythrocytes, karyorrhectic debris, and angiocentric inflammation.¹⁴ Direct immunofluorescence is not routinely performed but most commonly demonstrates deposition of IgA, IgM, and C3.^14,15

Levamisole-induced vasculopathy usually resolves upon cessation of cocaine use without long-term sequelae. Steroids have been used as treatment of prominent vasculitis with variable success; however, immunosuppressive effects should be closely monitored, especially with inpatients with concurrent granulocytopenia. Broad-spectrum antibiotics have been used in cases with fever and agranulocytosis. Cutaneous lesions typically disappear within 2 to 3 weeks, and serologic markers resolve within 2 to 10 months. Recurrent use of cocaine generally results in recurrent neutropenia and skin eruptions, supporting the causal role. Our patient’s recurrent prolonged cocaine use with vasculopathy was assumed to be the source of the necrotizing fasciitis that led to a cascade of sepsis, rapidly progressing multiorgan failure, and ultimate demise.

Presentation of a purpuric vasculopathy, with or without associated neutropenia and positive autoantibodies, should prompt the consideration of levamisole-contaminated cocaine use in the clinician’s differential. Although the patient may initially deny cocaine use, it is important to keep this diagnosis in mind when the clinical picture fits, and urine toxicology screen should be ordered when there is question. Physicians and patients should be wary of potential complications, even death. Early recognition and discontinuation of the offending agent could be lifesaving.

To the Editor:

Levamisole is a veterinary anthelmintic drug with immunomodulating properties that was once approved by the US Food and Drug Administration for the treatment of various conditions, including autoimmune diseases, cancer, pediatric kidney disease, and chronic infections.^1-4 Levamisole was banned in 2000 after reports of associated agranulocytosis and a characteristic painful purpuric vasculitis.^4,5 Despite the ban, its use persists due to its increasing incorporation as an adulterant in cocaine, presumably for its dopaminergic properties that potentiate psychotropic effects.⁶ In 2009, the Drug Enforcement Administration reported that 69% of seized cocaine in the United States contains this chemical, with an average concentration of 10%.⁵ Levamisole-induced vasculopathy (LIV) typically resolves following the cessation of cocaine without further treatment necessary. We present a fatal case of LIV to emphasize that early recognition and discontinuation of the offending agent could be lifesaving.

A 40-year-old woman with a history of cocaine abuse was admitted with tender, reticular, purpuric, and erythematous patches and plaques on the lower extremities with areas of necrosis (Figure 1). The lesions had been present intermittently for 6 months. She tried topical mupirocin and oral amoxicillin clavulanate without improvement. She also described polyarthralgia in the hands, but the remainder of the review of symptoms and physical examination was negative.

The pathogenesis of LIV is not completely understood, but it is thought to be an immune complex–mediated process based on immunofluorescence studies in the skin.^13,14 Classic pathologic findings include multiple fibrin thrombi within small vessels in the superficial and deep dermis, leukocytoclastic vasculitis of small vessels consisting of fibrinoid necrosis of the vessel wall, extravasated erythrocytes, karyorrhectic debris, and angiocentric inflammation.¹⁴ Direct immunofluorescence is not routinely performed but most commonly demonstrates deposition of IgA, IgM, and C3.^14,15

Levamisole-induced vasculopathy usually resolves upon cessation of cocaine use without long-term sequelae. Steroids have been used as treatment of prominent vasculitis with variable success; however, immunosuppressive effects should be closely monitored, especially with inpatients with concurrent granulocytopenia. Broad-spectrum antibiotics have been used in cases with fever and agranulocytosis. Cutaneous lesions typically disappear within 2 to 3 weeks, and serologic markers resolve within 2 to 10 months. Recurrent use of cocaine generally results in recurrent neutropenia and skin eruptions, supporting the causal role. Our patient’s recurrent prolonged cocaine use with vasculopathy was assumed to be the source of the necrotizing fasciitis that led to a cascade of sepsis, rapidly progressing multiorgan failure, and ultimate demise.

Presentation of a purpuric vasculopathy, with or without associated neutropenia and positive autoantibodies, should prompt the consideration of levamisole-contaminated cocaine use in the clinician’s differential. Although the patient may initially deny cocaine use, it is important to keep this diagnosis in mind when the clinical picture fits, and urine toxicology screen should be ordered when there is question. Physicians and patients should be wary of potential complications, even death. Early recognition and discontinuation of the offending agent could be lifesaving.

To the Editor:

Levamisole is a veterinary anthelmintic drug with immunomodulating properties that was once approved by the US Food and Drug Administration for the treatment of various conditions, including autoimmune diseases, cancer, pediatric kidney disease, and chronic infections.^1-4 Levamisole was banned in 2000 after reports of associated agranulocytosis and a characteristic painful purpuric vasculitis.^4,5 Despite the ban, its use persists due to its increasing incorporation as an adulterant in cocaine, presumably for its dopaminergic properties that potentiate psychotropic effects.⁶ In 2009, the Drug Enforcement Administration reported that 69% of seized cocaine in the United States contains this chemical, with an average concentration of 10%.⁵ Levamisole-induced vasculopathy (LIV) typically resolves following the cessation of cocaine without further treatment necessary. We present a fatal case of LIV to emphasize that early recognition and discontinuation of the offending agent could be lifesaving.

A 40-year-old woman with a history of cocaine abuse was admitted with tender, reticular, purpuric, and erythematous patches and plaques on the lower extremities with areas of necrosis (Figure 1). The lesions had been present intermittently for 6 months. She tried topical mupirocin and oral amoxicillin clavulanate without improvement. She also described polyarthralgia in the hands, but the remainder of the review of symptoms and physical examination was negative.

The pathogenesis of LIV is not completely understood, but it is thought to be an immune complex–mediated process based on immunofluorescence studies in the skin.^13,14 Classic pathologic findings include multiple fibrin thrombi within small vessels in the superficial and deep dermis, leukocytoclastic vasculitis of small vessels consisting of fibrinoid necrosis of the vessel wall, extravasated erythrocytes, karyorrhectic debris, and angiocentric inflammation.¹⁴ Direct immunofluorescence is not routinely performed but most commonly demonstrates deposition of IgA, IgM, and C3.^14,15

Levamisole-induced vasculopathy usually resolves upon cessation of cocaine use without long-term sequelae. Steroids have been used as treatment of prominent vasculitis with variable success; however, immunosuppressive effects should be closely monitored, especially with inpatients with concurrent granulocytopenia. Broad-spectrum antibiotics have been used in cases with fever and agranulocytosis. Cutaneous lesions typically disappear within 2 to 3 weeks, and serologic markers resolve within 2 to 10 months. Recurrent use of cocaine generally results in recurrent neutropenia and skin eruptions, supporting the causal role. Our patient’s recurrent prolonged cocaine use with vasculopathy was assumed to be the source of the necrotizing fasciitis that led to a cascade of sepsis, rapidly progressing multiorgan failure, and ultimate demise.

Presentation of a purpuric vasculopathy, with or without associated neutropenia and positive autoantibodies, should prompt the consideration of levamisole-contaminated cocaine use in the clinician’s differential. Although the patient may initially deny cocaine use, it is important to keep this diagnosis in mind when the clinical picture fits, and urine toxicology screen should be ordered when there is question. Physicians and patients should be wary of potential complications, even death. Early recognition and discontinuation of the offending agent could be lifesaving.

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

As the number of elderly patients with cancer continues to rise – and geriatricians remain in short supply – primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.

A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Dr. Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.

In most cases, informal geriatric assessment considers only the tip of the ‘geriatric oncology iceberg,’ including chronological age, performance status, tumor characteristics, and organ function, Dr. Williams noted.

In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.

“All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults,” Dr. Williams said.

He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Dr. Williams noted.

“It’s really more challenging to identify those individuals across the spectrum than those at the extremes,” Dr. Williams said, noting that formal geriatric assessment can detect problems not found routinely.
 

Formal geriatric assessment’s value

Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.

Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Dr. Williams noted.

Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.

“I think performing a geriatric assessment [prior to referral] would be a great idea. And that’s twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don’t need a referral to the oncologist if they’re particularly frail,” noted Dr. Williams.
 

Alternatives to formal assessments

When asked how providers can incorporate formal assessments into a busy day at the clinic, Dr. Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.

“Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported,” he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.

“[These assessments] can easily be completed before clinical visits or while in the waiting room,” Dr. Williams noted. “The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments.”

Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.

Courtesy Dr. Extermann

Gerontology remains a practice gap

Oncologists who don’t perform geriatric assessments are probably missing more than they think, Dr. Extermann said in an interview.

“Many oncologists don’t fully realize the importance of [geriatric assessment] yet,” Dr. Extermann said. “They kind of think that their internal medicine training will carry through, and they’ll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically.”

Gerontology remains a practice gap, Dr. Extermann said, not only within oncology, but across specialties.

“One of the big problems with the U.S. health care system is we don’t have enough geriatricians, and the reason we don’t have enough geriatricians is because we don’t pay them,” she said.

“Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn’t reimburse geriatric assessment, [and] it doesn’t reimburse geriatric consultation. [This] doesn’t motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front,” she explained.

Dr. Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Dr. Extermann reported no conflicts of interest.
 

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Jack. S. Remington, MD, the Stanford (Calif.) University clinical scientist who developed a test to identify babies at risk for dangerous toxoplasmosis, died on April 8 at the age of 90.

Dr. Remington was professor emeritus of infectious diseases at Stanford Medicine. A legendary researcher, Dr. Remington was described by colleagues and trainees as a dogged clinician. Known as “Stat Jack” for his sense of urgency, he retired in 2005.

He died after a fall; it was the last of many. When he wasn’t treating patients or conducting research, Dr. Remington was often rock climbing. Friends said he had broken many bones but was always a passionate climber.

Dr. Remington was retired when Upinder Singh, MD, arrived at Stanford. Now she is chief of infectious diseases and geographic medicine at Stanford Medicine. Dr. Singh said in an interview that Dr. Remington was a bright, forward-thinking scientist.

Dr. Remington conducted research at the Palo Alto Medical Foundation (PAMF), part of the Sutter Health network. He ran a toxoplasmosis serology lab, and it was his baby, Dr. Singh said. In 2019, it was renamed for him: The Dr Jack S. Remington Laboratory for Specialty Diagnostics.

While he conducted research at PAMF, he treated patients at Stanford, where he could see his research benefit them.

“What he held closest to his heart was that scientific endeavors should help patients,” Dr. Singh said.

Born in Chicago in 1931, Dr. Remington did his undergraduate work at Loyola University in Chicago and the University of Illinois, where he graduated from medical school in 1956, according to a statement from Stanford. He spent 2 years as a senior assistant surgeon for the United States Public Health Service and as a researcher at the National Institute of Allergy and Infectious Diseases.

There, he conducted key research on Toxoplasma gondii, a usually dormant parasite that poses a serious risk to anyone with a compromised immune system – a group that includes babies, transplant recipients, and people with HIV. T gondii is the reason pregnant women are told not to clean out litter boxes, because it can be spread through cat feces. Humans also contract toxoplasmosis by eating contaminated meat. The Centers for Disease Control and Prevention estimates that 300 to 4,000 babies are exposed each year and develop toxoplasmosis. Often symptom-free for a period, the children can go on to develop vision problems or developmental delays.

Dr. Remington developed a blood test that measures a baby’s exposure and, therefore, risk for toxoplasmosis. According to the Stanford announcement, “The test distinguished between antibodies that a newborn has passively acquired from its mother through the placental barrier and antibodies that indicate a newborn has actually been infected in the womb by pathogens, notably T. gondii, that had been residing in the mother’s tissues. The latter case meant a baby needed immediate treatment to stave off active toxoplasmosis.”

Dr. Remington also led clinical trials and developed drugs to treat the condition. Stanford reports that he authored or coauthored more than 600 articles and held 11 patents.

He also coauthored the most authoritative textbook in the field. Remington and Klein’s Infectious Diseases of the Fetus and Newborn Infant is now in its eighth edition.

Dr. Remington was elected a fellow of the American College of Physicians in 1966, the London-based Royal College of Physicians in 1999, the American Association for the Advancement of Science in 2000, and the American Academy of Microbiology in 2000. He was a past president of the Western Society for Clinical Research, the Infectious Diseases Society of America, and the International Immunocompromised Host Society.

Friends and colleagues remember him as a dedicated mentor, evidenced by the many trainees who traveled to his 70th birthday party, said Philip Pizzo, MD, professor of pediatrics and immunology at Stanford Medicine. Dr. Pizzo, the former dean of the School of Medicine, met Dr. Remington in 1977 after presenting a research paper on the subject of the immunocompromised host at a New York meeting of the Infectious Diseases Society of America. They became lifelong colleagues and friends.

Dr. Remington had his own kind of confidence and self-assurance, Dr. Pizzo said: “He climbed the most challenging rock faces in the world. It takes a certain kind of personality to do that.”

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

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Hepatic portal venous gas 

The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.¹ It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.² In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.³ 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.^2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.² 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Click here for the preview issue of the SHM Converge Daily News newsletter.

Click here for the preview issue of the SHM Converge Daily News newsletter.

Click here for the preview issue of the SHM Converge Daily News newsletter.

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. Here’s a preview of a recent popular clinical discussion:

From Jennifer Weiss, MD, MS, AGAF: Implementing CRC screening at 45:

The ACS recommended lowering the CRC screening age to 45, ACG has recently followed suit, and the USPSTF draft revisions also support a lower CRC screening age. In this month of colorectal cancer awareness, I was wondering how many people have started implementing this change in their practice and if they have received any pushback from insurance companies?

See how AGA members responded and join the discussion: https://community.gastro.org/posts/23923

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. Here’s a preview of a recent popular clinical discussion:

From Jennifer Weiss, MD, MS, AGAF: Implementing CRC screening at 45:

The ACS recommended lowering the CRC screening age to 45, ACG has recently followed suit, and the USPSTF draft revisions also support a lower CRC screening age. In this month of colorectal cancer awareness, I was wondering how many people have started implementing this change in their practice and if they have received any pushback from insurance companies?

See how AGA members responded and join the discussion: https://community.gastro.org/posts/23923

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. Here’s a preview of a recent popular clinical discussion:

From Jennifer Weiss, MD, MS, AGAF: Implementing CRC screening at 45:

The ACS recommended lowering the CRC screening age to 45, ACG has recently followed suit, and the USPSTF draft revisions also support a lower CRC screening age. In this month of colorectal cancer awareness, I was wondering how many people have started implementing this change in their practice and if they have received any pushback from insurance companies?

See how AGA members responded and join the discussion: https://community.gastro.org/posts/23923

This May, DDW will again be a virtual meeting. Not only does this pandemic continue, but it has re-emerged with a vengeance in several states. Michigan leads the nation in cases per 100,000, with the UK variant now predominant. Younger adults are being most impacted. There have been almost 250 confirmed COVID-19 cases in fully vaccinated people in Michigan. COVID-19 will be with us for a long time.

Despite the disruption caused by the coronavirus, scientific research and the need for up-to-date education continues. There are numerous educational sessions that will be available for us to view and opportunities for interacting with speakers in many. I hope you will take advantage of a virtual DDW to refresh knowledge and learn about new modalities to care for our patients.

Three cover stories this month should be of interest. A new AGA guideline has been published and it recognizes the advances made in construction and use of intragastric balloons. Current balloons positively add to weigh loss and, when used correctly, are safer and more effective than in the past. Gastroenterologists should enter the bariatric arena in multiple ways from lifestyle counseling to endoscopic therapies. We have much to add to this field. Another cover article concerns infliximab’s influence on development of COVID-19 antibodies. The last discusses how minority status influences liver transplant listing; we continue to uncover the impact of implicit bias in our medical decisions.

I hope you continue to take care of yourself, your families, and those in your communities. We are close to a return to normalcy but are not out of the woods yet. This is a time of reset in our nation, and we all should remember that we are a social network that works only when we look beyond ourselves. I have quoted Tom Friedman before: “Respect science, respect nature, respect each other.”

Have a happy and healthy spring.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This May, DDW will again be a virtual meeting. Not only does this pandemic continue, but it has re-emerged with a vengeance in several states. Michigan leads the nation in cases per 100,000, with the UK variant now predominant. Younger adults are being most impacted. There have been almost 250 confirmed COVID-19 cases in fully vaccinated people in Michigan. COVID-19 will be with us for a long time.

Despite the disruption caused by the coronavirus, scientific research and the need for up-to-date education continues. There are numerous educational sessions that will be available for us to view and opportunities for interacting with speakers in many. I hope you will take advantage of a virtual DDW to refresh knowledge and learn about new modalities to care for our patients.

Three cover stories this month should be of interest. A new AGA guideline has been published and it recognizes the advances made in construction and use of intragastric balloons. Current balloons positively add to weigh loss and, when used correctly, are safer and more effective than in the past. Gastroenterologists should enter the bariatric arena in multiple ways from lifestyle counseling to endoscopic therapies. We have much to add to this field. Another cover article concerns infliximab’s influence on development of COVID-19 antibodies. The last discusses how minority status influences liver transplant listing; we continue to uncover the impact of implicit bias in our medical decisions.

I hope you continue to take care of yourself, your families, and those in your communities. We are close to a return to normalcy but are not out of the woods yet. This is a time of reset in our nation, and we all should remember that we are a social network that works only when we look beyond ourselves. I have quoted Tom Friedman before: “Respect science, respect nature, respect each other.”

Have a happy and healthy spring.

John I. Allen, MD, MBA, AGAF
Editor in Chief

This May, DDW will again be a virtual meeting. Not only does this pandemic continue, but it has re-emerged with a vengeance in several states. Michigan leads the nation in cases per 100,000, with the UK variant now predominant. Younger adults are being most impacted. There have been almost 250 confirmed COVID-19 cases in fully vaccinated people in Michigan. COVID-19 will be with us for a long time.

Despite the disruption caused by the coronavirus, scientific research and the need for up-to-date education continues. There are numerous educational sessions that will be available for us to view and opportunities for interacting with speakers in many. I hope you will take advantage of a virtual DDW to refresh knowledge and learn about new modalities to care for our patients.

Three cover stories this month should be of interest. A new AGA guideline has been published and it recognizes the advances made in construction and use of intragastric balloons. Current balloons positively add to weigh loss and, when used correctly, are safer and more effective than in the past. Gastroenterologists should enter the bariatric arena in multiple ways from lifestyle counseling to endoscopic therapies. We have much to add to this field. Another cover article concerns infliximab’s influence on development of COVID-19 antibodies. The last discusses how minority status influences liver transplant listing; we continue to uncover the impact of implicit bias in our medical decisions.

I hope you continue to take care of yourself, your families, and those in your communities. We are close to a return to normalcy but are not out of the woods yet. This is a time of reset in our nation, and we all should remember that we are a social network that works only when we look beyond ourselves. I have quoted Tom Friedman before: “Respect science, respect nature, respect each other.”

Have a happy and healthy spring.

John I. Allen, MD, MBA, AGAF
Editor in Chief

It was estimated that physicians would diagnose a form of invasive cancer > 1.7 million times in 2019. As the second most common cause of death in the US, > 600,000 people were projected to die from cancer in 2019.¹ Many individuals with cancer endure distress, which the National Comprehensive Cancer Network (NCCN) defines as a “multifactorial unpleasant experience of a psychological (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.”^2,3 Distress in people living with cancer has been attributed to various psychosocial concerns, such as family problems, whichinclude dealing with partners and children; emotional problems, such as depression and anxiety; and physical symptoms, such as pain and fatigue.^4-9 Certain factors associated with distress may increase a patient’s risk for suicide.⁴

Veterans are at particularly high risk for suicide.¹⁰ In 2014, veterans accounted for 18% of completed suicides in the US but only were 8.5% of the total population that same year.¹⁰ Yet, little research has been done on the relationship between distress and suicide in veterans living with cancer. Aboumrad and colleagues found that 45% of veterans with cancer who completed suicide reported family issues and 41% endorsed chronic pain.¹¹ This study recommended continued efforts to assess and treat distress to lessen risk of suicide in veterans living with cancer; however, to date, only 1 study has specifically evaluated distress and problems endorsed among veterans living with cancer.⁷

Suicide prevention is of the highest priority to the US Department of Veterans Affairs (VA).¹² Consistent with the VA mission to end veteran suicide, the current study aimed to better understand the relationship between distress and suicide within a sample of veterans living with cancer. Findings would additionally be used to tailor clinical assessments and interventions for veterans living with cancer.

This study had 3 primary goals. First, we sought to understand demographic and clinical factors associated with low, moderate, and severe levels of distress in veterans living with cancer who were referred for psychology services. Second, the study investigated the most commonly endorsed problems by veterans living with cancer. Finally, we examined which problems were related to suicidal ideation (SI). It was hypothesized that veterans who reported severe distress would be significantly more likely to endorse SI when compared with veterans who reported mild or moderate distress. Based on existing literature, it was further hypothesized that family, emotional, and physical problems would be significantly associated with SI.^7,11

Methods

The current study was conducted at James A. Haley Veterans’ Hospital (JAHVH) in Tampa, Florida. Inclusion criteria included veterans who were diagnosed with cancer, attended an outpatient psychology-oncology evaluation, and completed mental health screening measures provided during their evaluation. Exclusion criteria included veterans who: were seen in response to an inpatient consult, were seen solely for a stem cell transplant evaluation, or did not complete the screening measures.

Measures

A veteran’s demographic (eg, age, sex, ethnicity) and clinical (eg, cancer type, stage of disease, recurrence, cancer treatments received) information was abstracted from their VA medical records. Marital status was assessed during a clinical interview and documented as part of the standardized suicide risk assessment.

The Distress Thermometer (DT) is a subjective measure developed by the NCCN.² The DT provides a visual representation of a thermometer and asks patients to rate their level of distress over the past week with 0 indicating no distress and 10 indicating extreme distress. A distress rating of 4 or higher is clinically significant.^4,6 Distress may be categorized into 3 levels of severity: mild distress (< 4), moderate distress (4-7), or severe distress (8-10). The DT has been found to have good face validity, sensitivity and specificity, and is user-friendly.^2,6,7,13

The measurement additionally lists 39 problems nested within 5 domains: practical, family, emotional, spiritual/religious, and physical. Patients may endorse listed items under each problem domain by indicating yes or no. Endorsement of various items are intended to provide more detailed information about sources of distress. Due to the predominantly male and mostly older population included in this study the ability to have children measure was removed from the family problem domain.

SI was assessed in 2 ways. First, by patients’ self-report through item-9 of the Patient Health Questionnaire-9 (PHQ-9).¹⁴ Item-9 asks “over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” Responses range from 0 (not at all) to 3 (nearly every day).¹⁴ Responses > 0 were considered a positive screen for SI. The process of administering the PHQ-9 item-9 is part of a national VA directive for standardizing assessment of suicide risk (Steve Young, personal communication, May 23, 2018). The PHQ-9 has been found to have good construct validity when used with both medical samples and the general population along with good internal and test-retest reliability.^14,15 Second, all veterans also were asked directly about SI during clinical interview, the results of which were documented in health records using a standardized format for risk assessment.

Procedure

Participants were a sample of veterans who were referred for psychology-oncology services. The NCCN DT and Problems List were administered prior to the start of clinical interviews, which followed a checklist and included standardized assessments of SI and history of a suicide attempt(s). A licensed clinical psychologist or a postdoctoral resident conducted these assessments under the supervision of a licensed psychologist. Data gathered during the clinical interview and from the DT and problems list were documented in health records, which were retrospectively reviewed for relevant information (eg, cancer diagnosis, SI). Therefore, informed consent was waived. This study was approved by the JAHVH Institutional Review Board.

Analysis

Data were analyzed using SPSS Version 25. Data analysis proceeded in 3 steps. First, descriptive statistics included the demographic and clinical factors present in the current sample. Difference between those with and without suicidal ideation were compared using F-statistic for continuous variables and χ² analyses for categorical variables. Second, to examine relationships between each DT problem domain and SI, χ² analyses were conducted. Third, DT problem domains that had a significant relationship with SI were entered in a logistic regression. This analysis determined which items, if any, from a DT problem domain predicted SI. In the logistic regression model, history of suicide attempts was entered into the first block, as history of suicide attempts is a well-established risk factor for subsequent suicidal ideation. In the second block, other variables that were significantly related to suicidal ideation in the second step of analyses were included. Before interpreting the results of the logistic regression, model fit was tested using the Hosmer-Lemeshow test. Significance of each individual predictor variable in the model is reported using the Wald χ² statistic; each Wald statistic is compared with a χ² distribution with 1 degree of freedom (df). Results of logistic regression models also provide information about the effect of each predictor variable in the regression equation (beta weight), odds a veteran who endorsed each predictor variable in the model would also endorse SI (as indicated by the odds ratio), and an estimate of the amount of variance accounted for by each predictor variable (using Nagelkerke’s pseudo R², which ranges in value from 0 to 1 with higher values indicating more variance explained). For all analyses, P value of .05 (2-tailed) was used for statistical significance.

Results

The sample consisted of 174 veterans (Table 1). The majority (77.6%) were male with a mean age of nearly 62 years (range, 29-87). Most identified as white (74.1%) with half reporting they were either married or living with a partner.

Prostate cancer (19.0%) was the most common type of cancer among study participants followed by head and neck (18.4%), lymphoma/leukemia (11.5%), lung (11.5%), and breast (10.9%); 31.6% had metastatic disease and 14.9% had recurrent disease. Chemotherapy (42.5%) was the most common treatment modality, followed by surgery (38.5%) and radiation (31.6%). The sample was distributed among the 3 distress DT categories: mild (18.4%), moderate (42.5%), and severe (39.1%).

Problems Endorsed

Treatment decisions (44.3%) and insurance/financial concerns (35.1%) were the most frequently endorsed practical problems (Figure 1). Family health issues (33.9%) and dealing with partner (23.0%) were the most frequently endorsed family problems (Figure 2). Worry (73.0%) and depression (69.5%) were the most frequent emotional problems; of note, all emotional problems were endorsed by at least 50% of veterans (Figure 3). Fatigue (71.3%), sleep (70.7%), and pain (69%), were the most frequently endorsed physical problems (Figure 4). Spiritual/religious problems were endorsed by 15% of veterans.

Suicidal Ideation

Overall, 25.3% of veterans endorsed SI. About 20% of veterans reported a history of ≥ 1 suicide attempts in their lifetime. A significant relationship among distress categories and SI was found (χ² = 18.36, P < .001). Veterans with severe distress were more likely to endorse SI (42.7%) when compared with veterans with mild (9.4%) or moderate (16.2%) distress.

Similarly, a significant relationship among distress categories and a history of a suicide attempt(s) was found (χ² = 6.08, P = .048). Veterans with severe distress were more likely to have attempted suicide (29.4%) when compared with veterans with mild (12.5%) or moderate (14.9%) distress.

Discussion

This study aimed to understand factors associated with low, moderate, and severe levels of distress in veterans living with cancer who were referred for psychology services. As hypothesized, veterans who endorsed severe distress were significantly more likely to endorse SI. They also were more likely to have a history of a suicide attempt(s) when compared with those with mild or moderate distress.

A second aim of this study was to understand the most commonly endorsed problems. Consistent with prior literature, treatment decisions were the most commonly endorsed practical problem; worry and depression were the most common emotional problems; and fatigue, sleep, and pain were the most common physical problems.⁷

A finding unique to the current study is that family health issues and dealing with partner were specified as the most common family problems. However, a study by Smith and colleagues did not provide information about the rank of most frequently reported problems within this domain.⁷

The third aim was to understand which problems were related to SI. It was hypothesized that family, emotional, and physical problems would be related to SI. However, results indicated that only family problems (specifically, problems dealing with a partner) were significantly associated with SI among veterans living with cancer.

Contrary to expectations, emotional and physical problems were not found to have a significant relationship with SI. This is likely because veterans endorsed items nested within these problem domains with similar frequency. The lack of significant findings does not suggest that emotional and physical problems are not significant predictors of SI for veterans living with cancer, but that no specific emotional or physical symptom stood out as a predictor of suicidal ideation above the others.

The finding of a significant relationship between family problems (specifically, problems dealing with a partner) and SI in this study is consistent with findings of Aboumrad and colleagues in a study that examined root-cause analyses of completed suicides by veterans living with cancer.¹¹ They found that nearly half the sample endorsed family problems prior to their death, and a small but notable percentage of veterans who completed suicide reported divorce as a stressor prior to their death.

This finding may be explained by Thomas Joiner's interpersonal-psychological theory of suicidal behavior (IPT), which suggests that completed suicide may result from a thwarted sense of belonging, perceived burdensomeness, and acquired capability for suicide.¹⁶ Problems dealing with a partner may impact a veteran’s sense of belonging or social connectedness. Problems dealing with a partner also may be attributed to perceived burdens due to limitations imposed by living with cancer and/or undergoing treatment. In both circumstances, the veteran’s social support system may be negatively impacted, and perceived social support is a well-established protective factor against suicide.¹⁷

Partner distress is a second consideration. It is likely that veterans’ partners experienced their own distress in response to the veteran’s cancer diagnosis and/or treatment. The partner’s cause, severity, and expression of distress may contribute to problems for the couple.

Finally, the latter point of the IPT refers to acquired capability, or the ability to inflict deadly harm to oneself.¹⁸ A military sample was found to have more acquired capability for suicide when compared with a college undergraduate sample.¹⁹ A history of a suicide attempt(s) and male gender have been found to significantly predict acquired capability to complete suicide.¹⁸ Furthermore, because veterans living with cancer often are in pain, fear of pain associated with suicide may be reduced and, therefore, acquired capability increased. This suggests that male veterans living with cancer who are in pain, have a history of a suicide attempt(s), and current problems with their partner may be an extremely vulnerable population at-risk for suicide. Results from the current study emphasize the importance of veterans having access to mental health and crisis resources for problems dealing with their partner. Partner problems may foreshadow a potentially lethal type of distress.

Strengths

This study’s aims are consistent with the VA’s mission to end veteran suicide and contributes to literature in several important ways.¹² First, veterans living with cancer are an understudied population. The current study addresses a gap in existing literature by researching veterans living with cancer and aims to better understand the relationship between cancer-related distress and SI. Second, to the best of the authors’ knowledge, this study is the first to find that problems dealing with a partner significantly increases a veteran’s risk for SI above a history of a suicide attempt(s). Risk assessments now may be more comprehensive through inclusion of this distress factor.

It is recommended that future research use IPT to further investigate the relationship between problems dealing with a partner and SI.¹⁶ Future research may do so by including specific measures to assess for the tenants of the theory, including measurements of burdensomeness and belongingness. An expanded knowledge base about what makes problems dealing with a partner a significant suicide risk factor (eg, increased conflict, lack of support, etc.) would better enable clinicians to intervene effectively. Effective intervention may lessen suicidal behaviors or deaths from suicides within the Veteran population.

Limitations

One limitation is the focus on patients who accepted a mental health referral. This study design may limit the generalizability of results to veterans who would not accept mental health treatment. The homogenous sample of veterans is a second limitation. Most participants were male, white, and had a mean age of 62 years. These demographics are representative of the veterans that most typically utilize VA services; however, more research is needed on veterans living with cancer who are female and of diverse racial and ethnic backgrounds. There are likely differences in problems endorsed and factors associated with SI based on age, race, sex, and other socioeconomic factors. A third limitation is the cross-sectional, retrospective nature of this study. Future studies are advised to assess for distress at multiple time points. This is consistent with NCCN Standards of Care for Distress Management.² Longitudinal data would enable more findings about distress and SI throughout the course of cancer diagnosis and treatment, therefore enhancing clinical implications and informing future research.

Conclusion

This is among the first of studies to investigate distress and factors associated with SI in veterans living with cancer who were referred for psychology services. The prevalence of distress caused by psychosocial factors (including treatment decisions, worry, and depression) highlights the importance of including mental health services as part of comprehensive cancer treatment.

Distress due to treatment decisions may be attributed to a litany of factors such as a veteran’s consideration of adverse effects, effectiveness of treatments, changes to quality of life or functioning, and inclusion of alternative or complimentary treatments. These types of decisions often are reported to be difficult conversations to have with family members or loved ones, who are likely experiencing distress of their own. The role of a mental health provider to assist veterans in exploring their treatment decisions and the implications of such decisions appears important to lessening distress.

Early intervention for emotional symptoms would likely benefit veterans’ management of distress and may lessen suicide risk as depression is known to place veterans at-risk for SI.²⁰ This underscores the importance of timely distress assessment to prevent mild emotional distress from progressing to potentially severe or life-threatening emotional distress. For veterans with a psychiatric history, timely assessment and intervention is essential because psychiatric history is an established suicide risk factor that may be exacerbated by cancer-related distress.¹²

Furthermore, management of intolerable physical symptoms may lessen risk for suicide.⁴ Under medical guidance, fatigue may be improved using exercise.²¹ Behavioral intervention is commonly used as first-line treatment for sleep problems.²² While pain may be lessened through medication or nonpharmacological interventions.²³

Considering the numerous ways that distress may present itself (eg, practical, emotional, or physical) and increase risk for SI, it is essential that all veterans living with cancer are assessed for distress and SI, regardless of their presentation. Although veterans may not outwardly express distress, this does not indicate the absence of either distress or risk for suicide. For example, a veteran may be distressed due to financial concerns, transportation issues, and the health of his/her partner or spouse. This veteran may not exhibit visible symptoms of distress, as would be expected when the source of distress is emotional (eg, depression, anxiety). However, this veteran is equally vulnerable to impairing distress and SI as someone who exhibits emotional distress. Distress assessments should be further developed to capture both the visible and less apparent sources of distress, while also serving the imperative function of screening for suicide. Other researchers also have noted the necessity of this development.²⁴ Currently, the NCCN DT and Problems List does not include any assessment of SI or behavior.

Finally, this study identified a potentially critical factor to include in distress assessment: problems dealing with a partner. Problems dealing with a partner have been noted as a source of distress in existing literature, but this is the first study to find problems dealing with a partner to be a predictor of SI in veterans living with cancer.^4-6

Because partners often attend appointments with veterans, it is not surprising that problems dealing with their partner are not disclosed more readily. It is recommended that clinicians ask veterans about potential problems with their partner when they are alone. Directly gathering information about such problems while assessing for distress may assist health care workers in providing the most effective, accurate type of intervention in a timely manner, and potentially mitigate risk for suicide.

As recommended by the NCCN and numerous researchers, findings from the current study underscore the importance of accurate, timely assessment of distress.^2,4,8 This study makes several important recommendations about how distress assessment may be strengthened and further developed, specifically for the veteran population. This study also expands the current knowledge base of what is known about veterans living with cancer, and has begun to fill a gap in the existing literature. Consistent with the VA mission to end veteran suicide, results suggest that veterans living with cancer should be regularly screened for distress, asked about distress related to their partner, and assessed for SI. Continued efforts to enhance assessment of and response to distress may lessen suicide risk in veterans with cancer.¹¹

Acknowledgements

This study is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

It was estimated that physicians would diagnose a form of invasive cancer > 1.7 million times in 2019. As the second most common cause of death in the US, > 600,000 people were projected to die from cancer in 2019.¹ Many individuals with cancer endure distress, which the National Comprehensive Cancer Network (NCCN) defines as a “multifactorial unpleasant experience of a psychological (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.”^2,3 Distress in people living with cancer has been attributed to various psychosocial concerns, such as family problems, whichinclude dealing with partners and children; emotional problems, such as depression and anxiety; and physical symptoms, such as pain and fatigue.^4-9 Certain factors associated with distress may increase a patient’s risk for suicide.⁴

Veterans are at particularly high risk for suicide.¹⁰ In 2014, veterans accounted for 18% of completed suicides in the US but only were 8.5% of the total population that same year.¹⁰ Yet, little research has been done on the relationship between distress and suicide in veterans living with cancer. Aboumrad and colleagues found that 45% of veterans with cancer who completed suicide reported family issues and 41% endorsed chronic pain.¹¹ This study recommended continued efforts to assess and treat distress to lessen risk of suicide in veterans living with cancer; however, to date, only 1 study has specifically evaluated distress and problems endorsed among veterans living with cancer.⁷

Suicide prevention is of the highest priority to the US Department of Veterans Affairs (VA).¹² Consistent with the VA mission to end veteran suicide, the current study aimed to better understand the relationship between distress and suicide within a sample of veterans living with cancer. Findings would additionally be used to tailor clinical assessments and interventions for veterans living with cancer.

This study had 3 primary goals. First, we sought to understand demographic and clinical factors associated with low, moderate, and severe levels of distress in veterans living with cancer who were referred for psychology services. Second, the study investigated the most commonly endorsed problems by veterans living with cancer. Finally, we examined which problems were related to suicidal ideation (SI). It was hypothesized that veterans who reported severe distress would be significantly more likely to endorse SI when compared with veterans who reported mild or moderate distress. Based on existing literature, it was further hypothesized that family, emotional, and physical problems would be significantly associated with SI.^7,11

Methods

The current study was conducted at James A. Haley Veterans’ Hospital (JAHVH) in Tampa, Florida. Inclusion criteria included veterans who were diagnosed with cancer, attended an outpatient psychology-oncology evaluation, and completed mental health screening measures provided during their evaluation. Exclusion criteria included veterans who: were seen in response to an inpatient consult, were seen solely for a stem cell transplant evaluation, or did not complete the screening measures.

Measures

A veteran’s demographic (eg, age, sex, ethnicity) and clinical (eg, cancer type, stage of disease, recurrence, cancer treatments received) information was abstracted from their VA medical records. Marital status was assessed during a clinical interview and documented as part of the standardized suicide risk assessment.

The Distress Thermometer (DT) is a subjective measure developed by the NCCN.² The DT provides a visual representation of a thermometer and asks patients to rate their level of distress over the past week with 0 indicating no distress and 10 indicating extreme distress. A distress rating of 4 or higher is clinically significant.^4,6 Distress may be categorized into 3 levels of severity: mild distress (< 4), moderate distress (4-7), or severe distress (8-10). The DT has been found to have good face validity, sensitivity and specificity, and is user-friendly.^2,6,7,13

The measurement additionally lists 39 problems nested within 5 domains: practical, family, emotional, spiritual/religious, and physical. Patients may endorse listed items under each problem domain by indicating yes or no. Endorsement of various items are intended to provide more detailed information about sources of distress. Due to the predominantly male and mostly older population included in this study the ability to have children measure was removed from the family problem domain.

SI was assessed in 2 ways. First, by patients’ self-report through item-9 of the Patient Health Questionnaire-9 (PHQ-9).¹⁴ Item-9 asks “over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” Responses range from 0 (not at all) to 3 (nearly every day).¹⁴ Responses > 0 were considered a positive screen for SI. The process of administering the PHQ-9 item-9 is part of a national VA directive for standardizing assessment of suicide risk (Steve Young, personal communication, May 23, 2018). The PHQ-9 has been found to have good construct validity when used with both medical samples and the general population along with good internal and test-retest reliability.^14,15 Second, all veterans also were asked directly about SI during clinical interview, the results of which were documented in health records using a standardized format for risk assessment.

Procedure

Participants were a sample of veterans who were referred for psychology-oncology services. The NCCN DT and Problems List were administered prior to the start of clinical interviews, which followed a checklist and included standardized assessments of SI and history of a suicide attempt(s). A licensed clinical psychologist or a postdoctoral resident conducted these assessments under the supervision of a licensed psychologist. Data gathered during the clinical interview and from the DT and problems list were documented in health records, which were retrospectively reviewed for relevant information (eg, cancer diagnosis, SI). Therefore, informed consent was waived. This study was approved by the JAHVH Institutional Review Board.

Analysis

Data were analyzed using SPSS Version 25. Data analysis proceeded in 3 steps. First, descriptive statistics included the demographic and clinical factors present in the current sample. Difference between those with and without suicidal ideation were compared using F-statistic for continuous variables and χ² analyses for categorical variables. Second, to examine relationships between each DT problem domain and SI, χ² analyses were conducted. Third, DT problem domains that had a significant relationship with SI were entered in a logistic regression. This analysis determined which items, if any, from a DT problem domain predicted SI. In the logistic regression model, history of suicide attempts was entered into the first block, as history of suicide attempts is a well-established risk factor for subsequent suicidal ideation. In the second block, other variables that were significantly related to suicidal ideation in the second step of analyses were included. Before interpreting the results of the logistic regression, model fit was tested using the Hosmer-Lemeshow test. Significance of each individual predictor variable in the model is reported using the Wald χ² statistic; each Wald statistic is compared with a χ² distribution with 1 degree of freedom (df). Results of logistic regression models also provide information about the effect of each predictor variable in the regression equation (beta weight), odds a veteran who endorsed each predictor variable in the model would also endorse SI (as indicated by the odds ratio), and an estimate of the amount of variance accounted for by each predictor variable (using Nagelkerke’s pseudo R², which ranges in value from 0 to 1 with higher values indicating more variance explained). For all analyses, P value of .05 (2-tailed) was used for statistical significance.

Results

The sample consisted of 174 veterans (Table 1). The majority (77.6%) were male with a mean age of nearly 62 years (range, 29-87). Most identified as white (74.1%) with half reporting they were either married or living with a partner.

Prostate cancer (19.0%) was the most common type of cancer among study participants followed by head and neck (18.4%), lymphoma/leukemia (11.5%), lung (11.5%), and breast (10.9%); 31.6% had metastatic disease and 14.9% had recurrent disease. Chemotherapy (42.5%) was the most common treatment modality, followed by surgery (38.5%) and radiation (31.6%). The sample was distributed among the 3 distress DT categories: mild (18.4%), moderate (42.5%), and severe (39.1%).

Problems Endorsed

Treatment decisions (44.3%) and insurance/financial concerns (35.1%) were the most frequently endorsed practical problems (Figure 1). Family health issues (33.9%) and dealing with partner (23.0%) were the most frequently endorsed family problems (Figure 2). Worry (73.0%) and depression (69.5%) were the most frequent emotional problems; of note, all emotional problems were endorsed by at least 50% of veterans (Figure 3). Fatigue (71.3%), sleep (70.7%), and pain (69%), were the most frequently endorsed physical problems (Figure 4). Spiritual/religious problems were endorsed by 15% of veterans.

Suicidal Ideation

Overall, 25.3% of veterans endorsed SI. About 20% of veterans reported a history of ≥ 1 suicide attempts in their lifetime. A significant relationship among distress categories and SI was found (χ² = 18.36, P < .001). Veterans with severe distress were more likely to endorse SI (42.7%) when compared with veterans with mild (9.4%) or moderate (16.2%) distress.

Similarly, a significant relationship among distress categories and a history of a suicide attempt(s) was found (χ² = 6.08, P = .048). Veterans with severe distress were more likely to have attempted suicide (29.4%) when compared with veterans with mild (12.5%) or moderate (14.9%) distress.

Discussion

This study aimed to understand factors associated with low, moderate, and severe levels of distress in veterans living with cancer who were referred for psychology services. As hypothesized, veterans who endorsed severe distress were significantly more likely to endorse SI. They also were more likely to have a history of a suicide attempt(s) when compared with those with mild or moderate distress.

A second aim of this study was to understand the most commonly endorsed problems. Consistent with prior literature, treatment decisions were the most commonly endorsed practical problem; worry and depression were the most common emotional problems; and fatigue, sleep, and pain were the most common physical problems.⁷

A finding unique to the current study is that family health issues and dealing with partner were specified as the most common family problems. However, a study by Smith and colleagues did not provide information about the rank of most frequently reported problems within this domain.⁷

The third aim was to understand which problems were related to SI. It was hypothesized that family, emotional, and physical problems would be related to SI. However, results indicated that only family problems (specifically, problems dealing with a partner) were significantly associated with SI among veterans living with cancer.

Contrary to expectations, emotional and physical problems were not found to have a significant relationship with SI. This is likely because veterans endorsed items nested within these problem domains with similar frequency. The lack of significant findings does not suggest that emotional and physical problems are not significant predictors of SI for veterans living with cancer, but that no specific emotional or physical symptom stood out as a predictor of suicidal ideation above the others.

The finding of a significant relationship between family problems (specifically, problems dealing with a partner) and SI in this study is consistent with findings of Aboumrad and colleagues in a study that examined root-cause analyses of completed suicides by veterans living with cancer.¹¹ They found that nearly half the sample endorsed family problems prior to their death, and a small but notable percentage of veterans who completed suicide reported divorce as a stressor prior to their death.

This finding may be explained by Thomas Joiner's interpersonal-psychological theory of suicidal behavior (IPT), which suggests that completed suicide may result from a thwarted sense of belonging, perceived burdensomeness, and acquired capability for suicide.¹⁶ Problems dealing with a partner may impact a veteran’s sense of belonging or social connectedness. Problems dealing with a partner also may be attributed to perceived burdens due to limitations imposed by living with cancer and/or undergoing treatment. In both circumstances, the veteran’s social support system may be negatively impacted, and perceived social support is a well-established protective factor against suicide.¹⁷

Partner distress is a second consideration. It is likely that veterans’ partners experienced their own distress in response to the veteran’s cancer diagnosis and/or treatment. The partner’s cause, severity, and expression of distress may contribute to problems for the couple.

Finally, the latter point of the IPT refers to acquired capability, or the ability to inflict deadly harm to oneself.¹⁸ A military sample was found to have more acquired capability for suicide when compared with a college undergraduate sample.¹⁹ A history of a suicide attempt(s) and male gender have been found to significantly predict acquired capability to complete suicide.¹⁸ Furthermore, because veterans living with cancer often are in pain, fear of pain associated with suicide may be reduced and, therefore, acquired capability increased. This suggests that male veterans living with cancer who are in pain, have a history of a suicide attempt(s), and current problems with their partner may be an extremely vulnerable population at-risk for suicide. Results from the current study emphasize the importance of veterans having access to mental health and crisis resources for problems dealing with their partner. Partner problems may foreshadow a potentially lethal type of distress.

Strengths

This study’s aims are consistent with the VA’s mission to end veteran suicide and contributes to literature in several important ways.¹² First, veterans living with cancer are an understudied population. The current study addresses a gap in existing literature by researching veterans living with cancer and aims to better understand the relationship between cancer-related distress and SI. Second, to the best of the authors’ knowledge, this study is the first to find that problems dealing with a partner significantly increases a veteran’s risk for SI above a history of a suicide attempt(s). Risk assessments now may be more comprehensive through inclusion of this distress factor.

It is recommended that future research use IPT to further investigate the relationship between problems dealing with a partner and SI.¹⁶ Future research may do so by including specific measures to assess for the tenants of the theory, including measurements of burdensomeness and belongingness. An expanded knowledge base about what makes problems dealing with a partner a significant suicide risk factor (eg, increased conflict, lack of support, etc.) would better enable clinicians to intervene effectively. Effective intervention may lessen suicidal behaviors or deaths from suicides within the Veteran population.

Limitations

One limitation is the focus on patients who accepted a mental health referral. This study design may limit the generalizability of results to veterans who would not accept mental health treatment. The homogenous sample of veterans is a second limitation. Most participants were male, white, and had a mean age of 62 years. These demographics are representative of the veterans that most typically utilize VA services; however, more research is needed on veterans living with cancer who are female and of diverse racial and ethnic backgrounds. There are likely differences in problems endorsed and factors associated with SI based on age, race, sex, and other socioeconomic factors. A third limitation is the cross-sectional, retrospective nature of this study. Future studies are advised to assess for distress at multiple time points. This is consistent with NCCN Standards of Care for Distress Management.² Longitudinal data would enable more findings about distress and SI throughout the course of cancer diagnosis and treatment, therefore enhancing clinical implications and informing future research.

Conclusion

This is among the first of studies to investigate distress and factors associated with SI in veterans living with cancer who were referred for psychology services. The prevalence of distress caused by psychosocial factors (including treatment decisions, worry, and depression) highlights the importance of including mental health services as part of comprehensive cancer treatment.

Distress due to treatment decisions may be attributed to a litany of factors such as a veteran’s consideration of adverse effects, effectiveness of treatments, changes to quality of life or functioning, and inclusion of alternative or complimentary treatments. These types of decisions often are reported to be difficult conversations to have with family members or loved ones, who are likely experiencing distress of their own. The role of a mental health provider to assist veterans in exploring their treatment decisions and the implications of such decisions appears important to lessening distress.

Early intervention for emotional symptoms would likely benefit veterans’ management of distress and may lessen suicide risk as depression is known to place veterans at-risk for SI.²⁰ This underscores the importance of timely distress assessment to prevent mild emotional distress from progressing to potentially severe or life-threatening emotional distress. For veterans with a psychiatric history, timely assessment and intervention is essential because psychiatric history is an established suicide risk factor that may be exacerbated by cancer-related distress.¹²

Furthermore, management of intolerable physical symptoms may lessen risk for suicide.⁴ Under medical guidance, fatigue may be improved using exercise.²¹ Behavioral intervention is commonly used as first-line treatment for sleep problems.²² While pain may be lessened through medication or nonpharmacological interventions.²³

Considering the numerous ways that distress may present itself (eg, practical, emotional, or physical) and increase risk for SI, it is essential that all veterans living with cancer are assessed for distress and SI, regardless of their presentation. Although veterans may not outwardly express distress, this does not indicate the absence of either distress or risk for suicide. For example, a veteran may be distressed due to financial concerns, transportation issues, and the health of his/her partner or spouse. This veteran may not exhibit visible symptoms of distress, as would be expected when the source of distress is emotional (eg, depression, anxiety). However, this veteran is equally vulnerable to impairing distress and SI as someone who exhibits emotional distress. Distress assessments should be further developed to capture both the visible and less apparent sources of distress, while also serving the imperative function of screening for suicide. Other researchers also have noted the necessity of this development.²⁴ Currently, the NCCN DT and Problems List does not include any assessment of SI or behavior.

Finally, this study identified a potentially critical factor to include in distress assessment: problems dealing with a partner. Problems dealing with a partner have been noted as a source of distress in existing literature, but this is the first study to find problems dealing with a partner to be a predictor of SI in veterans living with cancer.^4-6

Because partners often attend appointments with veterans, it is not surprising that problems dealing with their partner are not disclosed more readily. It is recommended that clinicians ask veterans about potential problems with their partner when they are alone. Directly gathering information about such problems while assessing for distress may assist health care workers in providing the most effective, accurate type of intervention in a timely manner, and potentially mitigate risk for suicide.

As recommended by the NCCN and numerous researchers, findings from the current study underscore the importance of accurate, timely assessment of distress.^2,4,8 This study makes several important recommendations about how distress assessment may be strengthened and further developed, specifically for the veteran population. This study also expands the current knowledge base of what is known about veterans living with cancer, and has begun to fill a gap in the existing literature. Consistent with the VA mission to end veteran suicide, results suggest that veterans living with cancer should be regularly screened for distress, asked about distress related to their partner, and assessed for SI. Continued efforts to enhance assessment of and response to distress may lessen suicide risk in veterans with cancer.¹¹

Acknowledgements

This study is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

It was estimated that physicians would diagnose a form of invasive cancer > 1.7 million times in 2019. As the second most common cause of death in the US, > 600,000 people were projected to die from cancer in 2019.¹ Many individuals with cancer endure distress, which the National Comprehensive Cancer Network (NCCN) defines as a “multifactorial unpleasant experience of a psychological (ie, cognitive, behavioral, emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.”^2,3 Distress in people living with cancer has been attributed to various psychosocial concerns, such as family problems, whichinclude dealing with partners and children; emotional problems, such as depression and anxiety; and physical symptoms, such as pain and fatigue.^4-9 Certain factors associated with distress may increase a patient’s risk for suicide.⁴

Veterans are at particularly high risk for suicide.¹⁰ In 2014, veterans accounted for 18% of completed suicides in the US but only were 8.5% of the total population that same year.¹⁰ Yet, little research has been done on the relationship between distress and suicide in veterans living with cancer. Aboumrad and colleagues found that 45% of veterans with cancer who completed suicide reported family issues and 41% endorsed chronic pain.¹¹ This study recommended continued efforts to assess and treat distress to lessen risk of suicide in veterans living with cancer; however, to date, only 1 study has specifically evaluated distress and problems endorsed among veterans living with cancer.⁷

Suicide prevention is of the highest priority to the US Department of Veterans Affairs (VA).¹² Consistent with the VA mission to end veteran suicide, the current study aimed to better understand the relationship between distress and suicide within a sample of veterans living with cancer. Findings would additionally be used to tailor clinical assessments and interventions for veterans living with cancer.

This study had 3 primary goals. First, we sought to understand demographic and clinical factors associated with low, moderate, and severe levels of distress in veterans living with cancer who were referred for psychology services. Second, the study investigated the most commonly endorsed problems by veterans living with cancer. Finally, we examined which problems were related to suicidal ideation (SI). It was hypothesized that veterans who reported severe distress would be significantly more likely to endorse SI when compared with veterans who reported mild or moderate distress. Based on existing literature, it was further hypothesized that family, emotional, and physical problems would be significantly associated with SI.^7,11

Methods

The current study was conducted at James A. Haley Veterans’ Hospital (JAHVH) in Tampa, Florida. Inclusion criteria included veterans who were diagnosed with cancer, attended an outpatient psychology-oncology evaluation, and completed mental health screening measures provided during their evaluation. Exclusion criteria included veterans who: were seen in response to an inpatient consult, were seen solely for a stem cell transplant evaluation, or did not complete the screening measures.

Measures

A veteran’s demographic (eg, age, sex, ethnicity) and clinical (eg, cancer type, stage of disease, recurrence, cancer treatments received) information was abstracted from their VA medical records. Marital status was assessed during a clinical interview and documented as part of the standardized suicide risk assessment.

The Distress Thermometer (DT) is a subjective measure developed by the NCCN.² The DT provides a visual representation of a thermometer and asks patients to rate their level of distress over the past week with 0 indicating no distress and 10 indicating extreme distress. A distress rating of 4 or higher is clinically significant.^4,6 Distress may be categorized into 3 levels of severity: mild distress (< 4), moderate distress (4-7), or severe distress (8-10). The DT has been found to have good face validity, sensitivity and specificity, and is user-friendly.^2,6,7,13

The measurement additionally lists 39 problems nested within 5 domains: practical, family, emotional, spiritual/religious, and physical. Patients may endorse listed items under each problem domain by indicating yes or no. Endorsement of various items are intended to provide more detailed information about sources of distress. Due to the predominantly male and mostly older population included in this study the ability to have children measure was removed from the family problem domain.

SI was assessed in 2 ways. First, by patients’ self-report through item-9 of the Patient Health Questionnaire-9 (PHQ-9).¹⁴ Item-9 asks “over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” Responses range from 0 (not at all) to 3 (nearly every day).¹⁴ Responses > 0 were considered a positive screen for SI. The process of administering the PHQ-9 item-9 is part of a national VA directive for standardizing assessment of suicide risk (Steve Young, personal communication, May 23, 2018). The PHQ-9 has been found to have good construct validity when used with both medical samples and the general population along with good internal and test-retest reliability.^14,15 Second, all veterans also were asked directly about SI during clinical interview, the results of which were documented in health records using a standardized format for risk assessment.

Procedure

Participants were a sample of veterans who were referred for psychology-oncology services. The NCCN DT and Problems List were administered prior to the start of clinical interviews, which followed a checklist and included standardized assessments of SI and history of a suicide attempt(s). A licensed clinical psychologist or a postdoctoral resident conducted these assessments under the supervision of a licensed psychologist. Data gathered during the clinical interview and from the DT and problems list were documented in health records, which were retrospectively reviewed for relevant information (eg, cancer diagnosis, SI). Therefore, informed consent was waived. This study was approved by the JAHVH Institutional Review Board.

Analysis

Data were analyzed using SPSS Version 25. Data analysis proceeded in 3 steps. First, descriptive statistics included the demographic and clinical factors present in the current sample. Difference between those with and without suicidal ideation were compared using F-statistic for continuous variables and χ² analyses for categorical variables. Second, to examine relationships between each DT problem domain and SI, χ² analyses were conducted. Third, DT problem domains that had a significant relationship with SI were entered in a logistic regression. This analysis determined which items, if any, from a DT problem domain predicted SI. In the logistic regression model, history of suicide attempts was entered into the first block, as history of suicide attempts is a well-established risk factor for subsequent suicidal ideation. In the second block, other variables that were significantly related to suicidal ideation in the second step of analyses were included. Before interpreting the results of the logistic regression, model fit was tested using the Hosmer-Lemeshow test. Significance of each individual predictor variable in the model is reported using the Wald χ² statistic; each Wald statistic is compared with a χ² distribution with 1 degree of freedom (df). Results of logistic regression models also provide information about the effect of each predictor variable in the regression equation (beta weight), odds a veteran who endorsed each predictor variable in the model would also endorse SI (as indicated by the odds ratio), and an estimate of the amount of variance accounted for by each predictor variable (using Nagelkerke’s pseudo R², which ranges in value from 0 to 1 with higher values indicating more variance explained). For all analyses, P value of .05 (2-tailed) was used for statistical significance.

Results

The sample consisted of 174 veterans (Table 1). The majority (77.6%) were male with a mean age of nearly 62 years (range, 29-87). Most identified as white (74.1%) with half reporting they were either married or living with a partner.

Prostate cancer (19.0%) was the most common type of cancer among study participants followed by head and neck (18.4%), lymphoma/leukemia (11.5%), lung (11.5%), and breast (10.9%); 31.6% had metastatic disease and 14.9% had recurrent disease. Chemotherapy (42.5%) was the most common treatment modality, followed by surgery (38.5%) and radiation (31.6%). The sample was distributed among the 3 distress DT categories: mild (18.4%), moderate (42.5%), and severe (39.1%).

Problems Endorsed

Treatment decisions (44.3%) and insurance/financial concerns (35.1%) were the most frequently endorsed practical problems (Figure 1). Family health issues (33.9%) and dealing with partner (23.0%) were the most frequently endorsed family problems (Figure 2). Worry (73.0%) and depression (69.5%) were the most frequent emotional problems; of note, all emotional problems were endorsed by at least 50% of veterans (Figure 3). Fatigue (71.3%), sleep (70.7%), and pain (69%), were the most frequently endorsed physical problems (Figure 4). Spiritual/religious problems were endorsed by 15% of veterans.

Suicidal Ideation

Overall, 25.3% of veterans endorsed SI. About 20% of veterans reported a history of ≥ 1 suicide attempts in their lifetime. A significant relationship among distress categories and SI was found (χ² = 18.36, P < .001). Veterans with severe distress were more likely to endorse SI (42.7%) when compared with veterans with mild (9.4%) or moderate (16.2%) distress.

Similarly, a significant relationship among distress categories and a history of a suicide attempt(s) was found (χ² = 6.08, P = .048). Veterans with severe distress were more likely to have attempted suicide (29.4%) when compared with veterans with mild (12.5%) or moderate (14.9%) distress.

Discussion

This study aimed to understand factors associated with low, moderate, and severe levels of distress in veterans living with cancer who were referred for psychology services. As hypothesized, veterans who endorsed severe distress were significantly more likely to endorse SI. They also were more likely to have a history of a suicide attempt(s) when compared with those with mild or moderate distress.

A second aim of this study was to understand the most commonly endorsed problems. Consistent with prior literature, treatment decisions were the most commonly endorsed practical problem; worry and depression were the most common emotional problems; and fatigue, sleep, and pain were the most common physical problems.⁷

A finding unique to the current study is that family health issues and dealing with partner were specified as the most common family problems. However, a study by Smith and colleagues did not provide information about the rank of most frequently reported problems within this domain.⁷

The third aim was to understand which problems were related to SI. It was hypothesized that family, emotional, and physical problems would be related to SI. However, results indicated that only family problems (specifically, problems dealing with a partner) were significantly associated with SI among veterans living with cancer.

Contrary to expectations, emotional and physical problems were not found to have a significant relationship with SI. This is likely because veterans endorsed items nested within these problem domains with similar frequency. The lack of significant findings does not suggest that emotional and physical problems are not significant predictors of SI for veterans living with cancer, but that no specific emotional or physical symptom stood out as a predictor of suicidal ideation above the others.

The finding of a significant relationship between family problems (specifically, problems dealing with a partner) and SI in this study is consistent with findings of Aboumrad and colleagues in a study that examined root-cause analyses of completed suicides by veterans living with cancer.¹¹ They found that nearly half the sample endorsed family problems prior to their death, and a small but notable percentage of veterans who completed suicide reported divorce as a stressor prior to their death.

This finding may be explained by Thomas Joiner's interpersonal-psychological theory of suicidal behavior (IPT), which suggests that completed suicide may result from a thwarted sense of belonging, perceived burdensomeness, and acquired capability for suicide.¹⁶ Problems dealing with a partner may impact a veteran’s sense of belonging or social connectedness. Problems dealing with a partner also may be attributed to perceived burdens due to limitations imposed by living with cancer and/or undergoing treatment. In both circumstances, the veteran’s social support system may be negatively impacted, and perceived social support is a well-established protective factor against suicide.¹⁷

Partner distress is a second consideration. It is likely that veterans’ partners experienced their own distress in response to the veteran’s cancer diagnosis and/or treatment. The partner’s cause, severity, and expression of distress may contribute to problems for the couple.

Finally, the latter point of the IPT refers to acquired capability, or the ability to inflict deadly harm to oneself.¹⁸ A military sample was found to have more acquired capability for suicide when compared with a college undergraduate sample.¹⁹ A history of a suicide attempt(s) and male gender have been found to significantly predict acquired capability to complete suicide.¹⁸ Furthermore, because veterans living with cancer often are in pain, fear of pain associated with suicide may be reduced and, therefore, acquired capability increased. This suggests that male veterans living with cancer who are in pain, have a history of a suicide attempt(s), and current problems with their partner may be an extremely vulnerable population at-risk for suicide. Results from the current study emphasize the importance of veterans having access to mental health and crisis resources for problems dealing with their partner. Partner problems may foreshadow a potentially lethal type of distress.

Strengths

This study’s aims are consistent with the VA’s mission to end veteran suicide and contributes to literature in several important ways.¹² First, veterans living with cancer are an understudied population. The current study addresses a gap in existing literature by researching veterans living with cancer and aims to better understand the relationship between cancer-related distress and SI. Second, to the best of the authors’ knowledge, this study is the first to find that problems dealing with a partner significantly increases a veteran’s risk for SI above a history of a suicide attempt(s). Risk assessments now may be more comprehensive through inclusion of this distress factor.

It is recommended that future research use IPT to further investigate the relationship between problems dealing with a partner and SI.¹⁶ Future research may do so by including specific measures to assess for the tenants of the theory, including measurements of burdensomeness and belongingness. An expanded knowledge base about what makes problems dealing with a partner a significant suicide risk factor (eg, increased conflict, lack of support, etc.) would better enable clinicians to intervene effectively. Effective intervention may lessen suicidal behaviors or deaths from suicides within the Veteran population.

Limitations

One limitation is the focus on patients who accepted a mental health referral. This study design may limit the generalizability of results to veterans who would not accept mental health treatment. The homogenous sample of veterans is a second limitation. Most participants were male, white, and had a mean age of 62 years. These demographics are representative of the veterans that most typically utilize VA services; however, more research is needed on veterans living with cancer who are female and of diverse racial and ethnic backgrounds. There are likely differences in problems endorsed and factors associated with SI based on age, race, sex, and other socioeconomic factors. A third limitation is the cross-sectional, retrospective nature of this study. Future studies are advised to assess for distress at multiple time points. This is consistent with NCCN Standards of Care for Distress Management.² Longitudinal data would enable more findings about distress and SI throughout the course of cancer diagnosis and treatment, therefore enhancing clinical implications and informing future research.

Conclusion

This is among the first of studies to investigate distress and factors associated with SI in veterans living with cancer who were referred for psychology services. The prevalence of distress caused by psychosocial factors (including treatment decisions, worry, and depression) highlights the importance of including mental health services as part of comprehensive cancer treatment.

Distress due to treatment decisions may be attributed to a litany of factors such as a veteran’s consideration of adverse effects, effectiveness of treatments, changes to quality of life or functioning, and inclusion of alternative or complimentary treatments. These types of decisions often are reported to be difficult conversations to have with family members or loved ones, who are likely experiencing distress of their own. The role of a mental health provider to assist veterans in exploring their treatment decisions and the implications of such decisions appears important to lessening distress.

Early intervention for emotional symptoms would likely benefit veterans’ management of distress and may lessen suicide risk as depression is known to place veterans at-risk for SI.²⁰ This underscores the importance of timely distress assessment to prevent mild emotional distress from progressing to potentially severe or life-threatening emotional distress. For veterans with a psychiatric history, timely assessment and intervention is essential because psychiatric history is an established suicide risk factor that may be exacerbated by cancer-related distress.¹²

Furthermore, management of intolerable physical symptoms may lessen risk for suicide.⁴ Under medical guidance, fatigue may be improved using exercise.²¹ Behavioral intervention is commonly used as first-line treatment for sleep problems.²² While pain may be lessened through medication or nonpharmacological interventions.²³

Considering the numerous ways that distress may present itself (eg, practical, emotional, or physical) and increase risk for SI, it is essential that all veterans living with cancer are assessed for distress and SI, regardless of their presentation. Although veterans may not outwardly express distress, this does not indicate the absence of either distress or risk for suicide. For example, a veteran may be distressed due to financial concerns, transportation issues, and the health of his/her partner or spouse. This veteran may not exhibit visible symptoms of distress, as would be expected when the source of distress is emotional (eg, depression, anxiety). However, this veteran is equally vulnerable to impairing distress and SI as someone who exhibits emotional distress. Distress assessments should be further developed to capture both the visible and less apparent sources of distress, while also serving the imperative function of screening for suicide. Other researchers also have noted the necessity of this development.²⁴ Currently, the NCCN DT and Problems List does not include any assessment of SI or behavior.

Finally, this study identified a potentially critical factor to include in distress assessment: problems dealing with a partner. Problems dealing with a partner have been noted as a source of distress in existing literature, but this is the first study to find problems dealing with a partner to be a predictor of SI in veterans living with cancer.^4-6

Because partners often attend appointments with veterans, it is not surprising that problems dealing with their partner are not disclosed more readily. It is recommended that clinicians ask veterans about potential problems with their partner when they are alone. Directly gathering information about such problems while assessing for distress may assist health care workers in providing the most effective, accurate type of intervention in a timely manner, and potentially mitigate risk for suicide.

As recommended by the NCCN and numerous researchers, findings from the current study underscore the importance of accurate, timely assessment of distress.^2,4,8 This study makes several important recommendations about how distress assessment may be strengthened and further developed, specifically for the veteran population. This study also expands the current knowledge base of what is known about veterans living with cancer, and has begun to fill a gap in the existing literature. Consistent with the VA mission to end veteran suicide, results suggest that veterans living with cancer should be regularly screened for distress, asked about distress related to their partner, and assessed for SI. Continued efforts to enhance assessment of and response to distress may lessen suicide risk in veterans with cancer.¹¹

Acknowledgements

This study is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.