Screening High-Risk Women Veterans for Breast Cancer
Background: Within the US Department of Veterans Affairs (VA), breast cancer prevalence has more than tripled from 1995 to 2012. Women veterans may be at an increased breast cancer risk based on service-related exposures and posttraumatic stress disorder (PTSD).
Methods: Women veterans aged ≥ 35 years with no personal history of breast cancer were enrolled at 2 urban VA medical centers. We surveyed women veterans for 5-year and lifetime risks of invasive breast cancer using the Gail Breast Cancer Risk Assessment Tool (BCRAT). Data regarding demographics, PTSD status, eligibility for chemoprevention, and genetic counseling were also collected. Descriptive statistics were used to determine results.
Results: A total of 99 women veterans participated, of which 60% were Black. In total, 35% were high risk with a 5-year BCRAT > 1.66%. Breast biopsies had been performed in 22% of our entire population; 57% had a family history positive for breast cancer. Comparatively, in our high-risk Black population, 33% had breast biopsies and 94% had a family history. High-risk patients were referred for chemoprevention; 5 accepted and 13 were referred for genetic counseling. PTSD was present in 31% of the high-risk subgroup.
Conclusions: A high percentage of Black patients participated in this pilot study, which also showed an above average rate of PTSD among women veterans who are at high risk for developing breast cancer. Historically, breast cancer rates among Black women are lower than those found in the general population. High participation among Black women veterans in this pilot study uncovered the potential for further study of this population, which is otherwise underrepresented in research. Limitations included a small sample size, exclusively urban population, and self-selection for screening. Future directions include the evaluation of genetic and molecular mutations in high risk Black women veterans, possibly even a role for PTSD epigenetic changes.
Conclusions
As the number of women veterans increases and the incidence of breast cancer in women veterans rise, chemoprevention options should follow national guidelines. To our knowledge, this is the only oncology study with 60% Black women veterans. This study had a higher participation rate for Black women veterans than is typically seen in national research studies and shows the VA to be a germane source for further understanding of an understudied population that may benefit from increased screening for breast cancer.
A team-based, multidisciplinary model that meets the unique healthcare needs of women veterans results in a patient-centric delivery of care for assessing breast cancer risk status and prevention options. This model can be replicated nationally by directing primary care physicians and women’s health practitioners to a risk-assessment questionnaire and referring high-risk women for appropriate preventative care. Given that these results show chemoprevention adherence rates doubled those seen nationally, perhaps techniques used within this VA pilot study may be adapted to decrease breast cancer incidence nationally.
Since the rate of PTSD among women veterans is triple the national average, we would expect adherence rates to be lower in our patient cohort. However, the multidisciplinary approach we used in this study (eg, 1:1 consultation with oncologist; genetic counseling referrals; mental health support available), may have improved adherence rates. Perhaps the high rates of PTSD seen in the VA patient population can be a useful way to explore patient adherence rates in those with mental illness and medical conditions.
Future research with a larger cohort may lead to greater insight into the correlation between PTSD and adherence to treatment. Exploring the connection between breast cancer, epigenetics, and specific military service-related exposures could be an area of analysis among this veteran population exhibiting increased breast cancer rates. VAMCs are situated in rural, suburban, and urban locations across the United States and offers a diverse socioeconomic and ethnic patient population for inclusion in clinical investigations. Women veterans make up a small subpopulation of women in the United States, but it is worth considering VA patients as an untapped resource for research collaboration.
Acknowledgements
The authors thank Steven Sanchez and Marissa Vallette, PhD, Breast Health Research Group. This research project was approved by the James J. Peters VA Medical Center Quality Executive Committee and the Washington, DC VA Medical Center Institutional Review Board. This work was supported by the US Department of Veterans Affairs. This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
