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Purpose The National TeleOncology Service (NTO) is a clinical service that enables VA oncologists, from across the country, to provide services via telehealth to Veterans with cancer. We sought to understand the early experiences of medical oncologists, Veterans, and clinical staff to inform the national NTO scale–out.Materials and methods We recruited clinicians who provided and/or Veterans who received care from three early adopting NTO sites. We purposively sampled Veteran participants who were: (1) diagnosed and/or treated December 2016 – March 2021 with prostate, non-small cell lung, non-Hodgkin's lymphoma, or colorectal cancer as confirmed by ICD–10 codes, and (2) obtained NTO-delivered care in October 2016 through July 2022 at one of the included NTO sites. We used rapid qualitative analysis.Results We conducted 3 provider focus groups and interviewed 15 Veterans. Participants noted the relative advantage of NTO over in-person care. A primary advantage of NTO is that it facilitates access to oncology specialists for Veterans who travel long distances. Clinicians and Veteran participants agreed that NTO service facilitates access to specialists for Veterans living far from VA medical facilities and community care and in areas lacking specialty oncologists. Although clinicians and Veteran participants agreed that NTO largely meets patient needs, some noted that NTO may not be personable.Conclusion There was consensus among clinicians that the NTO service, with its focus on specialized and individualized oncology care and increased access to care for patients through the virtual platform, is working well to meet the needs of Veterans with cancer.

Introduction: The KRAS G12C inhibitor sotorasib was approved for treating advanced NSCLC in the second line or later on the basis of the CodeBreaK100 trial. Nevertheless, data on the real-world efficacy and safety of sotorasib, and to its optimal dose, remain limited. Methods: Patients treated with sotorasib for NSCLC through the Veterans Health Administration were retrospectively identified from the Corporate Data Warehouse. Survival, response, and toxicity data were obtained from chart review. Results: Among the 128 patients treated with sotorasib through the Veterans Health Administration, objective response rate was 34%, progression-free survival (PFS) six months, and overall survival 12 months. Similar PFS was observed among the 16 patients who received frontline sotorasib without any prior systemic therapy for NSCLC. Toxicity leading to sotorasib interruption or dose reduction occurred in 37% of patients, whereas sotorasib discontinuation for toxicity occurred in 25%. Notably, sotorasib dose reduction was associated with substantially improved PFS and OS. Conclusions: In this real-world study, the observed efficacy of sotorasib was similar to the results of CodeBreaK100. Patients who received frontline sotorasib had similar PFS to our overall cohort, suggesting that first-line sotorasib monotherapy may benefit patients who are not eligible for chemotherapy. Toxicities leading to sotorasib interruption, dose reduction, or discontinuation were common. Sotorasib dose reduction was associated with improved survival, suggesting that sotorasib dose reduction may not compromise efficacy.

This study investigates the frequency of a clinically reported variant in PMS2, NM_000535.7:c.2523G>A p.(W841∗), from next-generation sequencing studies in 2 racially diverse cohorts. We identified clinical reports of the PMS2 c.2523G>A p.(W841∗) variant in the National Precision Oncology Program’s somatic testing database (n = 25,168). We determined frequency of the variant in germline exome sequencing from the Penn Medicine BioBank (n = 44,256) and in gnomAD. The PMS2 c.2523G>A p.(W841∗) was identified as a homozygous variant on tumor testing in an adult patient of self-identified Black race/ethnicity with no evidence of constitutional mismatch repair deficiency. The variant was clinically reported on 35 total tumor and liquid biopsy tests (0.1%), and all individuals with the variant were of self-identified Black race/ethnicity (0.6% of n = 5787). In individuals of African genetic ancestry (AFR), the variant's germline frequency was reported to be 0.2% and 1.3% in the Penn Medicine BioBank (PMBB) and gnomAD, respectively. The variant cannot be found in any individuals of European genetic ancestry (EUR) from either of the databases. The variant is found in a region of PMS2 with 100% homology to the PMS2CL pseudogene. PMS2 c.2523G>A p.(W841∗), when identified, is typically an African-ancestry-specific PMS2CL pseudogene variant, which should be recognized to prevent misdiagnosis of Lynch syndrome in Blacks.

Abstract Background Cancer diagnoses are associated with an increased risk for suicide. The aim of this study was to evaluate this association among Veterans receiving Veterans Health Administration (VHA) care, a population that has an especially high suicide risk. Methods Among 4,926,373 Veterans with VHA use in 2011 and in 2012 or 2013, and without VHA cancer diagnoses in 2011, we assessed suicide risk following incident cancer diagnoses. Risk time was from initial VHA use in 2012–2013 to 12/31/2018 or death, whichever came first. Cox proportional hazards regression models evaluated associations between new cancer diagnoses and suicide risk, adjusting for age, sex, VHA regional network, and mental health comorbidities. Suicide rates were calculated among Veterans with new cancer diagnoses through 84 months following diagnosis. Results A new cancer diagnosis corresponded to a 47% higher suicide risk (Adjusted Hazard Ratio [aHR] = 1.47, 95% CI: 1.33–1.63). The cancer subtype associated with the highest suicide risk was esophageal cancer (aHR = 6.01, 95% CI: 3.73–9.68), and other significant subtypes included head and neck (aHR = 3.55, 95% CI: 2.74–4.62) and lung cancer (aHR = 2.35, 95% CI: 1.85–3.00). Cancer stages 3 (aHR = 2.36, 95% CI: 1.80–3.11) and 4 (aHR = 3.53, 95% CI: 2.81–4.43) at diagnosis were positively associated with suicide risk. Suicide rates were highest within 3 months following diagnosis and remained elevated in the 3–6‐ and 6–12‐month periods following diagnosis. Conclusion Among Veteran VHA users, suicide risk was elevated following new cancer diagnoses. Risk was particularly high in the first 3 months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer.

Surface finish plays an essential role in the performance of superconducting radio frequency cavities. Several surface treatments have been developed to reduce surface resistance at a moderate accelerating gradient. We investigated the effects of sequential electropolishing on samples vacuum heat-treated at 300 and 600 °C and N-doped Nb samples using atomic force microscopy. The N-doping process precipitates niobium nitrides within grains and, most notably, continuously and deeply along some grain boundaries. Upon electropolishing, the nitrides are preferentially removed leaving behind a topographically imperfect surface marked by relatively deep holes and grooves with low radius of curvature edges. The progression of magnetic field enhancement and superheating field suppression factors upon electropolishing were investigated using atomic force micrographs. While minor changes in magnetic field enhancement and superheating field suppression factors are observed for the 300 and 600 °C heat-treated Nb, substantial improvements are observed for N-doped Nb. In this system, the most severe topographic defects are the grain boundary grooves which substantially suppress the superheating field. We find that the severity of topographic defects is related to the N-doping process.

Abstract Background The Veterans Health Administration (VHA) is the largest integrated health care system in the United States (US). Among VHA patients, the rate of use of concurrent chemoradiation therapy (CCRT) among those with unresectable, stage III non-small cell lung cancer (NSCLC) is unknown. The objective was to report recent CCRT treatment patterns in VHA patients and identify characteristics associated with receipt of CCRT. Methods Using Department of Veteran Affairs (VA) Cancer Registry System data linked to VA electronic medical records, we determined rates of CCRT, sequential CRT (SCRT), radiation therapy (RT) only, chemotherapy (CT) only, and neither treatment. Results Among 4054 VHA patients who met study criteria, CCRT rates slightly increased from 44 to 50% between 2013 and 2017. Factors associated with decreased odds of CCRT receipt compared to any other treatment included increasing age (adjusted odds ratio [aOR] per 10 years = 0.67; 95% CI: 0.60–0.76) and Charlson-Deyo comorbidity score (aOR = 0.94; 95% CI: 0.91–0.97). White race was associated with increased odds of CCRT receipt (aOR = 1.24; 95% CI: 1.004–1.53). In a chart review sample of 200 patients, less than half (n = 85) had a documented reason for not receiving CCRT. Among these, 29% declined treatment, and 71% did not receive CCRT due to “not being a candidate” for reasons related to frailty or lung nodules being too far apart for radiation therapy. Conclusions CCRT rates among VHA patients with unresectable, stage III NSCLC slightly increased from 2013 to 2017; however in 2017, only half were receiving CCRT. Older patients and those with multiple comorbidities were less likely to receive CCRT and even when controlling for these factors, non-white patients were less likely to receive CCRT.

Abstract Background Transportation barriers limit access to cancer care services and contribute to suboptimal clinical outcomes. Our objectives were to describe the frequency of Veterans reporting and the factors associated with transportation barriers to or from colorectal cancer (CRC) care visits. Methods Between November 2015 and September 2016, Veterans with incident stage I, II, or III CRC completed a mailed survey to assess perceived barriers to recommended care. Participants who reported difficulty with transportation to or from CRC care appointments were categorized as experiencing transportation barriers. We assessed pairwise correlations between transportation barriers, transportation-related factors (e.g., mode of travel), and chaotic lifestyle (e.g., predictability of schedules), and used logistic regression to examine the association between the reporting of transportation difficulties, distance traveled to the nearest Veterans Affairs (VA) facility, and life chaos. Results Of the 115 Veterans included in this analysis, 18% reported experiencing transportation barriers. Distance to the VA was not strongly correlated with the reporting of transportation barriers (Spearman’s ρ = 0.12, p = 0.19), but chaotic lifestyle was both positively and significantly correlated with experiencing transportation barriers (Spearman’s ρ = 0.22, p = 0.02). Results from the logistic regression model modestly supported the findings from the pairwise correlations, but were not statistically significant. Conclusions Transportation is an important barrier to or from CRC care visits, especially among Veterans who experience greater life chaos. Identifying Veterans who experience chaotic lifestyles would allow for timely engagement in behavioral interventions (e.g., organizational skills training) and with support services (e.g., patient navigation).

Background: Epidermal growth factor receptor (EGFR) mutation testing is recommended in metastatic non-small cell lung cancer (NSCLC). The objective of this study was to assess changes in EGFR mutation testing patterns and tyrosine kinase inhibitor (TKI) use in US veterans with stage III-IV NSCLC between 2013 and 2017. Patients and Methods: Retrospective study using linked data from Department of Veterans Affairs (VA) Cancer Registry System, Corporate Data Warehouse, commercial laboratories, and clinical notes. Generalized linear mixed models accounting for clustering by VA facility were used to determine factors associated with EGFR mutation testing. Results: From 2013 to 2017, EGFR mutation testing increased from 29.5% to 38.4% among veterans with stage III-IV NSCLC and from 47.0% to 57.4% among veterans with stage IV non-squamous disease. Factors associated with increased odds of testing included being married, Medicare enrollment, and adenocarcinoma histology. Factors associated with decreased odds of testing included Medicaid eligibility, stage III disease, increasing age, being a current or former smoker, increasing Charlson-Deyo comorbidity score, and receiving cancer care in the South. Appropriate use of a TKI rose from 2013 to 2017 (17.2% to 74.1%). Conclusion: EGFR mutation testing rates increased to almost 60% in the stage IV non-squamous NSCLC population in 2017, with residual opportunity for further increase. Several sociodemographic characteristics, comorbidities, and geographic regions were associated with EGFR mutation testing suggestive of inequitable testing decisions. Appropriate use of TKI improved drastically from 2013 to 2017 demonstrating rapidly changing practice patterns through the adoption phase of new treatment options.

Hepatitis B virus (HBV) reactivation may occur with high risk immunosuppression, such as anti‐cluster of differentiation (CD)20 antibodies (Abs). Appropriate HBV prophylaxis during anti‐CD20 Ab therapy averts hepatitis, chemotherapy disruption, and death. Serologic evidence of prior HBV exposure is present in one in nine veterans in the Veterans Health Administration (VHA). In 2014, most (61%‐73%) patients in the VHA who were receiving anti‐CD20 Ab treatment underwent HBV testing, yet 90% and antiviral prophylaxis to >80%.

Abstract Background Colorectal cancer (CRC) is the third most commonly diagnosed cancer in the US. CRC survivors may have complex healthcare needs requiring care from both specialists and primary care. Our objective was to understand how CRC survivors perceive their survivorship care, especially management of their cardiovascular-related chronic diseases. Methods We identified patients diagnosed with non-metastatic CRC between 10/1/2007 and 12/31/2015 at Veterans Affairs Medical Centers in North Carolina or Virginia. In 2016, we conducted telephone-based, semi-structured interviews to assess survivors’ experiences with cancer survivorship and changes in health priorities. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed, and coded. Results The 25 participants were, on average, 64 years old and approximately 4 years post-CRC diagnosis at the time of interview; most were white (60%), male (92%), and diagnosed with colon cancer (64%) as opposed to rectal cancer. CRC survivors reported: (1) a shift in focus from surviving cancer to reducing cardiovascular disease risk (e.g., by managing weight); (2) challenges with taking medications for CVD-related conditions; (3) new recognition of the importance of engaging with primary care providers. Conclusions Experiences with cancer shapes how survivors view their health. Management of cardiovascular-related chronic disease is important to veteran CRC survivors. There is a need to deliver cardiovascular disease risk reduction programs tailored for CRC survivors.

Abstract Background Current clinical guidelines recommend epidermal growth factor receptor (EGFR) mutational testing in patients with metastatic non-small cell lung cancer (NSCLC) to predict the benefit of the tyrosine kinase inhibitor erlotinib as first-line treatment. Proteomic (VeriStrat) testing is recommended for patients with EGFR negative or unknown status when erlotinib is being considered. Departure from this clinical algorithm can increase costs and may result in worse outcomes. We examined EGFR and proteomic testing among patients with NSCLC within the Department of Veterans Affairs (VA). We explored adherence to guidelines and the impact of test results on treatment decisions and cost of care. Methods Proteomic and EGFR test results from 2013 to 2015 were merged with VA electronic health records and pharmacy data. Chart reviews were conducted. Cases were categorized based on the appropriateness of testing and treatment. Results Of the 69 patients with NSCLC who underwent proteomic testing, 33 (48%) were EGFR-negative and 36 (52%) did not have documented EGFR status. We analyzed 138 clinical decisions surrounding EGFR/proteomic testing and erlotinib treatment. Most decisions (105, or 76%) were concordant with clinical practice guidelines. However, for 24 (17%) decisions documentation of testing or justification of treatment was inadequate, and 9 (7%) decisions represented clear departures from guidelines. Conclusion EGFR testing, the least expensive clinical intervention analyzed in this study, was significantly underutilized or undocumented. The records of more than half of the patients lacked information on EGFR status. Our analysis illustrated several clinical scenarios where the timing of proteomic testing and erlotinib diverged from the recommended algorithm, resulting in excessive costs of care with no documented improvements in health outcomes.

A simplified numerical model has been developed to simulate nonlinear superconducting radiofrequency (SRF) losses on Nb surfaces. This study focuses exclusively on excessive surface resistance (R_{s}) losses due to the microscopic topographical magnetic field enhancements. When the enhanced local surface magnetic field exceeds the superconducting critical transition magnetic field H_{c}, small volumes of surface material may become normal conducting and increase the effective surface resistance without inducing a quench. We seek to build an improved quantitative characterization of this qualitative model. Using topographic data from typical buffered chemical polish (BCP)- and electropolish (EP)-treated fine grain niobium, we have estimated the resulting field-dependent losses and extrapolated this model to the implications for cavity performance. The model predictions correspond well to the characteristic BCP versus EP high field Q_{0} performance differences for fine grain niobium. We describe the algorithm of the model, its limitations, and the effects of this nonlinear loss contribution on SRF cavity performance.

Interior surfaces of niobium cavities used in superconducting radio frequency accelerators are now obtained by buffered chemical polish and/or electropolish. Laser polishing is a potential alternative, having advantages of speed, freedom from noxious chemistry and availability of in-process inspection. We studied the influence of the laser power density and laser beam raster rate on the surface topography. These two factors need to be combined carefully to smooth the surface without damage. Computational modeling was used to estimate the surface temperature and gain insight into the mechanism of laser polishing. Power spectral density analysis of surface topography measurements shows that laser polishing can produce smooth topography similar to that obtained by electropolish. This is a necessary first step toward introducing laser polishing as an alternative to the currently practiced chemical polishing.

Microroughness is viewed as a critical issue for attaining optimum performance of superconducting radio frequency accelerator cavities. The principal surface smoothing methods are buffered chemical polish (BCP) and electropolish (EP). The resulting topography is characterized by atomic force microscopy (AFM). The power spectral density (PSD) of AFM data provides a more thorough description of the topography than a single-value roughness measurement. In this work, one dimensional average PSD functions derived from topography of BCP and EP with different controlled starting conditions and durations have been fitted with a combination of power law, K correlation, and shifted Gaussian models to extract characteristic parameters at different spatial harmonic scales. While the simplest characterizations of these data are not new, the systematic tracking of scale-specific roughness as a function of processing is new and offers feedback for tighter process prescriptions more knowledgably targeted at beneficial niobium topography for superconducting radio frequency applications.

Surface topography characterization is a continuing issue for the superconducting radio frequency (SRF) particle accelerator community. Efforts are under way to both improve surface topography and its characterization and analysis using various techniques. In measurement of topography, power spectral density (PSD) is a promising method to quantify typical surface parameters and develop scale-specific interpretations. PSD can also be used to indicate how the process modifies topography at different scales. However, generating an accurate and meaningful topographic PSD of an SRF surface requires careful analysis and optimization. In this report, niobium surfaces with different process histories are sampled with atomic force microscopy and stylus profilometry and analyzed to trace topography evolution at different scales. An optimized PSD analysis protocol to serve SRF needs is presented.

Nb3Sn (TC ≈ 18 K and HSh ≈ 400 mT) is a prospective material to replace Nb (TC ≈ 9 K and Hsh ≈ 200 mT) in SRF accelerator cavities for significant cost reduction and performance enhancement. Because of its material properties, Nb3Sn is best employed as a thin film (coating) inside an already built RF cavity structure. A particular test cavity noted as C3C4 was a 1.5 GHz single-cell Nb cavity, coated with Nb3Sn using Sn vapor diffusion process at Jefferson Lab. Cold measurements of the coated cavity indicated the superconducting transition temperature of about 18 K. Subsequent RF measurements indicated field-dependent surface resistance both at 4.3 and 2.0 K. After initial cold measurements, the cavity RF loss distribution was studied with a thermometry mapping system. Loss regions were identified with thermometry and were cut out for material analysis. The presence of significantly thin patchy regions and other carbon-rich defects is associated with strong local field-dependent surface resistance. This paper summarizes RF and thermometry results correlated with material science findings. [ABSTRACT FROM AUTHOR]

Nb3Sn offers significant potential to exceed the performance of niobium for superconducting radio frequency accelerator cavities. The most promising path toward deployment is by tin vapor diffusion coating of Nb cavity interiors via a two step nucleation-then-growth sequence. Reported here is a materials science study of the nucleation process. We manipulated the accessible range of process variables and determined the effect on composition and microstructure using an array of materials characterization tools. Broadly, nucleation deposits tin as a thin surface phase and, under some conditions, as near-micron sized particles as well, resembling Stranski–Krastanov growth. Conditions that impair nucleation promote the formation of defects, such as patches, in subsequent coating growth. Otherwise no significant effect on the subsequently grown coating was found for structures produced during nucleation. [ABSTRACT FROM AUTHOR]

BackgroundTo support the rising need for testing and to standardize tumor DNA sequencing practices within the U.S. Department of Veterans Affairs (VA)'s Veterans Health Administration (VHA), the National Precision Oncology Program (NPOP) was launched in 2016. We sought to assess oncologists' practices, concerns, and perceptions regarding Next-Generation Sequencing (NGS) and the NPOP.Materials and methodsUsing a purposive total sampling approach, oncologists who had previously ordered NGS for at least one tumor sample through the NPOP were invited to participate in semi-structured interviews. Questions assessed the following: expectations for the NPOP, procedural requirements, applicability of testing results, and the summative utility of the NPOP. Interviews were assessed using an open coding approach. Thematic analysis was conducted to evaluate the completed codebook. Themes were defined deductively by reviewing the direct responses to interview questions as well as inductively by identifying emerging patterns of data.ResultsOf the 105 medical oncologists who were invited to participate, 20 (19%) were interviewed from 19 different VA medical centers in 14 states. Five recurrent themes were observed: (1) Educational Efforts Regarding Tumor DNA Sequencing Should be Undertaken, (2) Pathology Departments Share a Critical Role in Facilitating Test Completion, (3) Tumor DNA Sequencing via NGS Serves as the Most Comprehensive Testing Modality within Precision Oncology, (4) The Availability of the NPOP Has Expanded Options for Select Patients, and (5) The Completion of Tumor DNA Sequencing through the NPOP Could Help Improve Research Efforts within VHA Oncology Practices.ConclusionMedical oncologists believe that the availability of tumor DNA sequencing through the NPOP could potentially lead to an improvement in outcomes for veterans with metastatic solid tumors. Efforts should be directed toward improving oncologists' understanding of sequencing, strengthening collaborative relationships between oncologists and pathologists, and assessing the role of comprehensive NGS panels within the battery of precision tests.

Immune checkpoint inhibitors, a class of drugs used in approximately forty unique cancer indications, are a sizable component of the economic burden of cancer care in the US. Instead of personalized weight-based dosing, immune checkpoint inhibitors are most commonly administered at "one-size-fits-all" flat doses that are higher than necessary for the vast majority of patients. We hypothesized that personalized weight-based dosing along with common stewardship efforts at the pharmacy level, such as dose rounding and vial sharing, would lead to reductions in immune checkpoint inhibitor use and lower spending. Using data from the Veterans Health Administration (VHA) and Medicare drug prices, we estimated reductions in immune checkpoint inhibitor use and spending that would be associated with pharmacy-level stewardship strategies, in a case-control simulation study of individual patient-level immune checkpoint inhibitor administration events. We identified baseline annual VHA spending for these drugs of approximately $537 million. Combining weight-based dosing, dose rounding, and pharmacy-level vial sharing would generate expected annual VHA health system savings of $74 million (13.7 percent). We conclude that adoption of pharmacologically justified immune checkpoint inhibitor stewardship measures would generate sizable reductions in spending for these drugs. Combining these operational innovations with value-based drug price negotiation enabled by recent policy changes may improve the long-term financial viability of cancer care in the US.

Competing Interests: Daphne R. FriedmanStock and Other Ownership Interests: Biogen, CVS Health Corp (CVS), Johnson & Johnson (JNJ), United Health Group, Zoetis IncResearch Funding: Loxo/Lilly (Inst), Oncopeptides (Inst), TG Therapeutics (Inst) Ahmad S. HalwaniResearch Funding: Bristol Myers Squibb (Inst), Kyowa Hakko Kirin (Inst), Roche/Genentech (Inst), AbbVie/Genentech (Inst), AbbVie (Inst), Immune Design (Inst), miRagen (Inst), Amgen (Inst), Seattle Genetics (Inst), Genentech (Inst), Takeda (Inst), Pharmacyclics (Inst), Bayer (Inst)Travel, Accommodations, Expenses: Pharmacyclics, AbbVie, Seattle Genetics, Immune Design Michael J. KelleyResearch Funding: Novartis (Inst), AstraZeneca (Inst), Bristol Myers Squibb (Inst), Regeneron (Inst), Genentech (Inst)Other Relationship: IBM (Inst)Open Payments Link: https://openpaymentsdata.cms.gov/physician/827136No other potential conflicts of interest were reported.

Aim: To evaluate pretreatment hepatitis B virus (HBV) testing, vaccination, and antiviral treatment rates in Veterans Affairs patients receiving anti-CD20 Ab for quality improvement., Methods: We performed a retrospective cohort study using a national repository of Veterans Health Administration (VHA) electronic health record data. We identified all patients receiving anti-CD20 Ab treatment (2002-2014). We ascertained patient demographics, laboratory results, HBV vaccination status (from vaccination records), pharmacy data, and vital status. The high risk period for HBV reactivation is during anti-CD20 Ab treatment and 12 mo follow up. Therefore, we analyzed those who were followed to death or for at least 12 mo after completing anti-CD20 Ab. Pretreatment serologic tests were used to categorize chronic HBV (hepatitis B surface antigen positive or HBsAg+), past HBV (HBsAg-, hepatitis B core antibody positive or HBcAb+), resolved HBV (HBsAg-, HBcAb+, hepatitis B surface antibody positive or HBsAb+), likely prior vaccination (isolated HBsAb+), HBV negative (HBsAg-, HBcAb-), or unknown. Acute hepatitis B was defined by the appearance of HBsAg+ in the high risk period in patients who were pretreatment HBV negative. We assessed HBV antiviral treatment and the incidence of hepatitis, liver failure, and death during the high risk period. Cumulative hepatitis, liver failure, and death after anti-CD20 Ab initiation were compared by HBV disease categories and differences compared using the χ(2) test. Mean time to hepatitis peak alanine aminotransferase, liver failure, and death relative to anti-CD20 Ab administration and follow-up were also compared by HBV disease group., Results: Among 19304 VHA patients who received anti-CD20 Ab, 10224 (53%) had pretreatment HBsAg testing during the study period, with 49% and 43% tested for HBsAg and HBcAb, respectively within 6 mo pretreatment in 2014. Of those tested, 2% (167/10224) had chronic HBV, 4% (326/7903) past HBV, 5% (427/8110) resolved HBV, 8% (628/8110) likely prior HBV vaccination, and 76% (6022/7903) were HBV negative. In those with chronic HBV infection, ≤ 37% received HBV antiviral treatment during the high risk period while 21% to 23% of those with past or resolved HBV, respectively, received HBV antiviral treatment. During and 12 mo after anti-CD20 Ab, the rate of hepatitis was significantly greater in those HBV positive vs negative (P = 0.001). The mortality rate was 35%-40% in chronic or past hepatitis B and 26%-31% in hepatitis B negative. In those pretreatment HBV negative, 16 (0.3%) developed acute hepatitis B of 4947 tested during anti-CD20Ab treatment and follow-up., Conclusion: While HBV testing of Veterans has increased prior to anti-CD20 Ab, few HBV+ patients received HBV antivirals, suggesting electronic health record algorithms may enhance health outcomes.

Purpose: The optimal chemotherapy regimen to use with radiotherapy in stage III non-small-cell lung cancer is unknown. Here, we compare the outcome of patents treated within the Veterans Health Administration with either etoposide-cisplatin (EP) or carboplatin-paclitaxel (CP)., Methods: We identified patients treated with EP and CP with concurrent radiotherapy from 2001 to 2010. Survival rates were compared using Cox proportional hazards regression models with adjustments for confounding provided by propensity score methods and an instrumental variables analysis. Comorbidities and treatment complications were identified through administrative data., Results: A total of 1,842 patients were included; EP was used in 27% (n = 499). Treatment with EP was not associated with a survival advantage in a Cox proportional hazards model (hazard ratio [HR], 0.97; 95% CI, 0.85 to 1.10), a propensity score matched cohort (HR, 1.07; 95% CI, 0.91 to 1.24), or a propensity score adjusted model (HR, 0.97; 95% CI, 0.85 to 1.10). In an instrumental variables analysis, there was no survival advantage for patients treated in centers where EP was used more than 50% of the time as compared with centers where EP was used in less than 10% of the patients (HR, 1.07; 95% CI, 0.90 to 1.26). Patients treated with EP, compared with patients treated with CP, had more hospitalizations (2.4 v 1.7 hospitalizations, respectively; P < .001), outpatient visits (17.6 v 12.6 visits, respectively; P < .001), infectious complications (47.3% v 39.4%, respectively; P = .0022), acute kidney disease/dehydration (30.5% v 21.2%, respectively; P < .001), and mucositis/esophagitis (18.6% v 14.4%, respectively; P = .0246)., Conclusion: After accounting for prognostic variables, patients treated with EP versus CP had similar overall survival, but EP was associated with increased morbidity., (© 2014 by American Society of Clinical Oncology.)