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Abstract

Background:

There is an increase in breast and gynecologic cancer cases treated within Veterans Health Administration (VHA).

Objectives:

To describe the age and race of Veteran women diagnosed with breast and gynecologic cancers in VHA and compare with U.S. women broadly.

Design:

Retrospective, cross-sectional study.

Methods:

We obtained data from January 1, 2021 to March 12, 2024 from the Breast and Gynecologic Oncology System of Excellence (BGSoE) dashboard and for women covered in the 2021 Surveillance, Epidemiology, and End Results (SEER) program.

Results:

In the Veteran cohort (n = 6555), the median age is 59 and 58 years for breast and gynecologic cancers, respectively. ~52% (n = 2586) of breast cancers are diagnosed among non-Hispanic Whites, ~30% (n = 1519) among non-Hispanic Blacks, and 6% (n = 301) among Hispanics. For gynecologic cancers, ~58% (n = 897) are diagnosed among non-Hispanic Whites, ~23% (n = 359) among non-Hispanic Blacks, and ~7% (n = 108) among Hispanics.

Conclusions:

Compared to SEER, women Veterans are diagnosed at younger ages and have similar racial composition.

Keywords

women cancer Veterans

Introduction

The Veterans Health Administration (VHA) of the Department of Veterans Affairs is a high-volume provider of cancer care, managing approximately 400,000 prevalent cancer cases and 50,000 new cancer cases each year.¹ Historically, the majority of VHA users have been male. Accordingly, the types of cancers treated in the VHA have reflected this demographic, with prostate cancer being the most commonly diagnosed and treated cancer historically in the VHA.^2,3 However, the composition of the VHA patient population is evolving. Women are the fastest-growing group among Veterans, and by 2040, they are projected to make up nearly 20% of the population.⁴ Women are also the fastest-growing population of Veterans enrolled in VHA for their health care; the VHA now has more women enrolled than ever before.⁵ Due to the historically smaller size of the women Veteran population, previous research on women Veterans with cancer treated within the VHA has been limited.^6,7 As more women Veterans seek care through the VHA, there is an increased focus on deepening the understanding of the incidence of cancers that predominantly affect women Veterans seeking VHA health care. To ensure the best possible cancer care for women Veterans, the VHA established the Breast and Gynecologic Oncology System of Excellence (BGSoE) in 2021.⁸

Since its inception, the BGSoE has focused on identifying Veterans newly diagnosed with breast and gynecologic cancers, providing telehealth oncology services, and coordinating cancer care and support for those Veterans. While establishing BGSoE has been an important first step in optimizing care for women Veterans with cancer, there remains a limited understanding of characteristics, experiences, and needs of women Veterans diagnosed with breast and gynecologic cancers.

In response to this critical knowledge gap, the VHA established COURAGE, an oncology outcomes program dedicated to evaluating the quality of cancer care received by Veterans diagnosed with breast or gynecologic cancer. COURAGE aims to partner with and evaluate the BGSoE with the shared goal of strengthening cancer care services within the VHA. As an initial step, in this paper, we describe the characteristics—specifically age, race, and geographic region—of women Veterans diagnosed with breast and/or gynecologic cancer as reported in the BGSoE dashboard. To characterize this population of women Veterans, we conducted a parallel, narrative comparison with women newly diagnosed with breast and gynecologic cancers in the general U.S. population using data from the Surveillance, Epidemiology, and End Results (SEER) program and VHA. Our findings provide a detailed comparison of incident breast and gynecologic cancers diagnosed among women by age, race, and region.

Materials and methods

We utilized the BGSoE dashboard to gather data on women Veterans diagnosed with breast or gynecologic cancer between January 1, 2021 and March 12, 2024.⁹ The dashboard combines text-mining techniques from physician referrals with associated ICD-10-CM diagnostic codes from the VHA’s electronic health record system to identify eligible Veterans diagnosed with breast cancer with a precision and F1 of 95% and gynecologic cancers with precision of 96.2% and F1 of 87%.¹⁰ The overall implementation uses a human in the loop approach, and the algorithm was associated with an accuracy of 96% and 87% for breast and gynecologic cancer, respectively, when performance was assessed against provider review.¹¹ The human in the loop approach consisted of a medical provider reviewing electronic health record data to confirm an incident breast or gynecologic cancer diagnosis. We supplemented the BGSoE cancer diagnosis data with data from the VHA Corporate Data Warehouse (CDW) to describe geographic region, race, ethnicity, and age. For VA data, we did not perform an age adjustment due to insufficient data for a reference population. We excluded men diagnosed with breast cancer from these analyses. We included all women reported in the BGSoE with a confirmed incident breast or gynecologic cancer diagnosis.

For a broader understanding of cancer incidence across the United States, we utilized the SEER Program of the National Cancer Institute.¹² SEER consists of population-based registries that cover approximately 48% of the U.S. population. Our analysis includes cases and underlying populations for U.S. women residing in regions covered by the 22 SEER registries as of 2021.

This is a non-research determination for the National Oncology Program evaluation in line with guidance from the Department of Veterans Affairs Office of Research and Development Program Guide 1200.21. Due to this guidance, participants did not provide informed consent to participate. SEER data are publicly available. We do not report individual information. The reporting of this study conforms to the STROBE statement.¹³

Results

We focus on women Veterans by presenting incidence of both cancer types (Tables 1 and 2) and geographic region (Figure 1).

Table 1.

Age-adjusted breast cancer incidence in women Veterans Affairs patients.

Age category	FY 2024 VA women Veteran population	Cancer incidence	Cancers, n	Crude incidence per 100k
<25	44,000	0.00007	3	6.8
25–34	292,000	0.00042	123	42.1
35–44	420,000	0.00142	595	141.7
45–54	407,000	0.00303	1234	303.2
55–64	459,000	0.00354	1627	354.5
65–74	314,000	0.00367	1151	366.6
75–84	107,000	0.00211	226	211.2
85+	43,000	0.00098	42	97.7
All ages	2,086,000	0.00240	5001	239.7

Table 2.

Age-adjusted gynecologic cancer incidence in women Veterans Affairs patients.

Age category	FY 2024 VA women Veteran population	Cancer incidence	Cancers, n	Crude incidence per 100k
<25	44,000	0.00016	7	15.9
25–34	292,000	0.00040	116	39.7
35–44	420,000	0.00055	231	55.0
45–54	407,000	0.00072	294	72.2
55–64	459,000	0.00113	519	113.1
65–74	314,000	0.00101	317	101.0
75–84	107,000	0.00060	64	59.8
85+	43,000	0.00014	6	14.0
All ages	2,086,000	0.00074	1554	74.5

Figure 1.

Geographic region of women with breast and gynecologic cancer.

The BGSoE dashboard screening algorithm identified 6555 women Veterans with breast or gynecologic cancers from January 1, 2021 to March 12, 2024. Most of these women Veterans (76%, n = 5001) were diagnosed with breast cancer. Among women Veterans diagnosed with breast cancer, most were non-Hispanic White (52%, n = 2586), followed by non-Hispanic Black (30%, n = 1519), other racial groups (12%, n = 595), and Hispanic ethnicity (6%, n = 301). Among women Veterans diagnosed with gynecologic cancers (n = 1554), most were non-Hispanic White (58%, n = 897), followed by non-Hispanic Black (23%, n = 358), other racial groups (12%, n = 191), and Hispanic (7%, n = 108) race and ethnicity.

We calculated age at entry date into the BGSoE dashboard, which should approximate the cancer diagnosis date. The median age at diagnosis was 59 years old. For women Veterans with breast cancer, the median age at diagnosis was 59; for gynecologic cancers, it was 58. Tables 1 and 2 show cancer incidence rates among women Veterans by age category for fiscal year 2024 for breast and gynecologic cancers, respectively. The total population of female Veterans across all ages is 2,086,000, with 6555 cancers reported and an overall crude incidence rate of 314.2 per 100,000. Younger age groups have lower cancer rates, with the <25 category reporting the lowest crude incidence of 22.7 per 100,000. Both tables demonstrate that incidence rates increase with age, but breast cancer rates are consistently lower than the overall cancer rates across all age groups. The crude overall cancer incidence and breast cancer incidence are both higher than the gynecologic cancer incidence, which has a crude rate of 74.5 per 100,000 and 1554 cases. While overall incidence increases with age, gynecologic cancers have the lowest rates across all age groups, particularly in Veterans aged 75 and older.

Figure 1 shows the regional distribution of cancer cases among women Veterans in fiscal year 2024, with crude cancer incidence rates calculated per 100,000 population. The West has the highest crude incidence rate at 179.8 per 100,000 (1591 cases among 884,952 women Veterans), followed by the South at 160.8 per 100,000 (3337 cases among 2,075,454 women Veterans). The Northeast has a rate of 141.8 per 100,000 (609 cases among 429,329 women Veterans), and the Midwest reports the lowest rate at 134.4 per 100,000 (1018 cases among 757,239 women Veterans).

Discussion

Despite women being the fastest growing demographic receiving care in the VHA, little is known about demographic of veterans being diagnosed with reproductive cancers. In this retrospective analysis, we have found that veterans diagnosed with breast and gynecologic cancers are diagnosed at a younger age than a civilian cohort of patients.

Women Veterans are younger than women in the general population. The median age of women Veterans is 51 years, while the median age for non-Veteran women is approximately 47 years.¹⁴ The age distribution of women Veterans is trimodal with peaks at ages 32, 53, and 91. The median age of women Veterans is 53 years.¹⁵ Each peak represents a different life stage with unique health care needs, including cancer risk and cancer screening needs. In the BGSoE data, we identified a median age of 59 and 58 years, respectively, for the median age at entry into the dashboard of breast or gynecologic cancer. This is a noteworthy finding because the age at which breast and gynecologic cancers are presenting for women Veterans is considerably younger than is reported in SEER. In SEER, the median age for breast cancer diagnosis is 63 years and, while it varies for gynecologic cancers (e.g., median diagnosis age is 63 years for ovarian cancer, 60 years for endometrial cancer, and 35–44 years for cervical cancer), the ages are generally younger in the VHA than in the general U.S. population of women. Unfortunately, our data lack information regarding menopausal status; thus, our report focuses on age. Regarding screening rates, in 2021, an estimated 75% of women were up to date on breast and 72% for cervical cancer screening.^16,17 Screening rates are slightly higher among women Veterans receiving VHA health care, with estimates suggesting that 78% of women Veterans are up to date on breast cancer screening.^18,19 Breast cancer is the most diagnosed cancer among women Veterans in the VHA. Additionally, compared to women in the general U.S. population, data suggest that women Veterans may have an increased risk of developing breast cancer based on prior military service-related exposures.^20
–23

We identified approximately 52% of breast cancer diagnoses to be among non-Hispanic white Veteran women. In fiscal year 2020, the VHA reported that approximately 53% of women using the VHA were White.²⁴ Thus, the racial composition of Veteran women diagnosed with breast cancer is generally comparable to the racial composition of women Veterans receiving VHA care. Additionally, the racial composition of cancers identified in the VHA data mirrors that reported in SEER. According to SEER data, non-Hispanic White women have the highest incidence of breast cancer, followed by non-Hispanic black women, and other racial groups.²⁵ An unanswered question is whether there are racial differences in VHA breast cancer care. A systematic review of literature on racial and ethnic health disparities among women using the VA broadly, not necessarily those with cancer or breast cancer, concluded that there is limited information about health care disparities specifically among women Veterans.²⁶ The potential for cancer care disparities in VHA has been examined, not breast cancer specifically, and at least one study identified no or modest disparities, many of which are attributable to within-hospital differences.²⁷ Future research could examine whether there are racial differences in the desirability of using VHA for breast cancer care or in cancer care quality and outcomes.

Limitations

This study had four important limitations. First, many Veterans are represented in the SEER data. While SEER does not directly identify patients as Veterans in its data, Veterans who are treated for their cancer at non-VA facilities may be included in SEER. Additionally, while the VA Central Cancer Registry does not contribute data to SEER, some VHA facilities may contribute data to their state cancer registries, which may subsequently report to SEER. We anticipate that this limitation would have minimal impact on our work due to our data sources and the cancer registry reporting lag time. More specifically, we did not use data from the VA Central Cancer Registry or from hospital-based cancer registries within the VHA. Instead, we reported data from a curated BGSoE dashboard supplemented with CDW data, which is updated nightly. Cancer registries have a reporting lag. For example, SEER allows a standard reporting lag time of 22 months. The second limitation is due to the current capacity of the BGSoE case identification algorithm to differentiate cancer type with sufficient specificity for reporting purposes. The algorithm is currently accurate to differentiate breast and gynecologic cancers; however, we are currently unable to differentiate between different types of gynecologic cancers (e.g., ovarian, endometrial, etc.) with sufficient sensitivity for reporting. Future research could assess whether omitting VA health care system users from SEER would have an impact on outcome. Because we do not have access to identifiable VA and SEER data, we are not able to conduct this analysis at this time. A third limitation is that the BGSOE algorithm is finetuned for the clinical use case of identifying women actively seeking evaluation or treatment for breast or gynecologic cancer in the VA or through VA-supported community care. Some of these Veterans might have had some of their diagnostic workup or management occurring outside the support of VA healthcare system or community care programs. Finally, because we did not have data available regarding cancer risk for both cohorts (e.g., body mass index, smoking status) we were not able to account for behavioral risk factors differences.

An important strength of this study is that compared to prior reporting of cancer among women Veterans using data from nearly 15 years ago,⁷ we identified a higher volume of women Veterans diagnosed with breast and gynecologic cancers. This is likely due to both the increase in women Veterans using the VHA overall and due to the more novel, sensitive, and timely case identification approaches being employed by the BGSoE dashboard. Previous studies relied exclusively on diagnostic codes and did not include the innovative data processes of the BGSoE dashboard. However, even with these novel approaches for case identification, this may underestimate the number of women Veterans with breast cancer given that the incident rate in the United States is broadly one in eight.

Conclusion

In summary, we provide an updated reporting of women Veterans diagnosed with breast and gynecologic cancers receiving care in the VHA. Compared to prior reporting, we found an increasing volume of women Veterans diagnosed with these cancers. Our findings regarding racial and geographic composition of women Veterans diagnosed with breast and gynecologic cancers were consistent with the underlying population of women using the VHA for their health care and with the general U.S. population of women reported by SEER. However, we found that women Veterans were diagnosed at earlier ages than their general U.S. counterparts. There is a need to identify women with cancer earlier to inform health care delivery planning.

Supplemental Material

sj-doc-1-whe-10.1177_17455057251399013 – Supplemental material for Characteristics of women Veterans with incident breast and gynecologic cancers in the Veterans Health Administration

Supplemental material, sj-doc-1-whe-10.1177_17455057251399013 for Characteristics of women Veterans with incident breast and gynecologic cancers in the Veterans Health Administration by Leah L. Zullig, Megan Shepherd-Banigan, Graham L. Cummin, Theodore S. Berkowitz, Alexander Melamed, Hollis Weidenbacher, Erin M. Bayley, Sarah Colonna, Elizabeth Hulen, Vikas Patil, Ahmad Halwani, Michael J. Kelley and Haley Moss in Women’s Health

Footnotes

Acknowledgements

We acknowledge the National Oncology Program for their support.

Author’s Note

Megan Shepherd-Banigan is now affiliated with Mid-Atlantic MIRECC, Durham VA Health Care System, Durham, NC, USA; 4-Duke-Margolis Health Policy Institute, Duke University, Durham NC, USA.

ORCID iDs

Leah L. Zullig

Megan Shepherd-Banigan

Ethical considerations

Consent to participate

Participants did not provide informed consent to participate. SEER data are publicly available.

Consent for publication

Not applicable.

Author contributions

Leah L. Zullig: Conceptualization; Funding acquisition; Writing – original draft; Writing – review & editing; Methodology; Supervision.

Megan Shepherd-Banigan: Conceptualization; Writing – original draft; Writing – review & editing; Methodology.

Graham L. Cummin: Formal analysis; Methodology; Writing – review & editing; Visualization.

Theodore S. Berkowitz: Formal analysis; Methodology; Writing – review & editing; Visualization.

Alexander Melamed: Writing – review & editing.

Hollis Weidenbacher: Project administration.

Erin M. Bayley: Writing – review & editing.

Sarah Colonna: Writing – review & editing.

Elizabeth Hulen: Writing – review & editing.

Vikas Patil: Formal analysis; Methodology; Writing – review & editing.

Ahmad Halwani: Writing – review & editing.

Michael J. Kelley: Writing – review & editing.

Haley Moss: Writing – review & editing; Conceptualization; Funding acquisition; Methodology; Supervision.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this work was provided by the Center of Innovation to Accelerate Discovery and Practice Transformation at the Durham VA Health Care System (Grant No. CIN 13-410). We also thank the National Oncology Program for financially supporting this work. Megan Shepherd-Banigan, PhD, was funded by a VA HSR&D Career Development Award (17-006). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors are U.S. government employees or receive financial support from the U.S. government. Dr. Zullig has consulting, unrelated to the current work, for Eisai.

Data availability statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research, supporting data are not available.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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