News

Immunosuppressive therapy and transplant strategies are critical in the management of immune aplastic anemia (AA), a hematologist told colleagues during a recent Association of VA Hematology/Oncology (AVAHO) webinar on rare and ultrarare blood disorders. But the first major challenge is diagnosis, said Emma M. Groarke, MD, of the National Heart, Lung, and Blood Institute at the National Institutes of Health.

According to Groarke, patients with bone marrow failure—a large category that includes AA—typically present with bone marrow hypocellularity (abnormally few cells) and reticulocytopenia (abnormally few immature blood cells). But these conditions also may be the result of other disorders, such as malignant cancer, medication-induced cytopenias, vitamin deficiencies, infection, or advanced liver disease.

After diagnosing a patient with bone marrow hypocellularity, clinicians need to consider whether the underlying etiology is immune or inherited, she said. Radiation can also cause AA, but that is not common outside chemotherapy.

“In younger patients, you have a higher threshold of suspicion for an inherited or germline disorder,” she said. “Whereas in older patients, it's more likely to be acquired or immune-mediated. It’s really important to differentiate these because the treatments are very different depending on whether this is immune-mediated versus genetic.”

Treatment Options: Transplant

Everyone diagnosed with severe AA should be seen by a transplant specialist and have human leukocyte antigens typing and donors identified “because things can change very quickly,” Groarke said. However, hematopoietic stem cell transplant isn’t for everyone. While it is often offered to patients aged < 40 years with a matched sibling donor, older adults typically take medication instead because of the higher transplant-related mortality risk.

“It’s really individualized for patients,” Groarke explained. Patients aged ≥ 40 years with profound neutropenia may be good candidates for transplantation despite their age. Younger patients with less severe disease may not require immediate transplant, she said.

Treatment Options: Medication

Groarke, who coauthored a 2023 American Society of Hematology report on inherited bone marrow failure in adults, said that horse antithymocyte globulin (ATG) and cyclosporin have been “the mainstay” of treatment for older adults with immune AA based on a 1995 Blood study. Response rates were 67% by 3 months and 70% to 80% by 1 year.

Researchers tried for years to boost responses but failed until the rise of a combination therapy that includes ATG, cyclosporin, and eltrombopag. This combination therapy has become the standard of care.

There have been questions about using ATG in patients aged > 60 years. Groarke said research supports the medication in this population. “They seem to respond equally well as younger patients,” she said.

While older patients do have more cardiac complications, Groarke said her clinic still administers ATG to them. However, “the one history that gives us some pause is a significant cardiac history.”

Disclosures for Groarke were not provided.

Immunosuppressive therapy and transplant strategies are critical in the management of immune aplastic anemia (AA), a hematologist told colleagues during a recent Association of VA Hematology/Oncology (AVAHO) webinar on rare and ultrarare blood disorders. But the first major challenge is diagnosis, said Emma M. Groarke, MD, of the National Heart, Lung, and Blood Institute at the National Institutes of Health.

According to Groarke, patients with bone marrow failure—a large category that includes AA—typically present with bone marrow hypocellularity (abnormally few cells) and reticulocytopenia (abnormally few immature blood cells). But these conditions also may be the result of other disorders, such as malignant cancer, medication-induced cytopenias, vitamin deficiencies, infection, or advanced liver disease.

After diagnosing a patient with bone marrow hypocellularity, clinicians need to consider whether the underlying etiology is immune or inherited, she said. Radiation can also cause AA, but that is not common outside chemotherapy.

“In younger patients, you have a higher threshold of suspicion for an inherited or germline disorder,” she said. “Whereas in older patients, it's more likely to be acquired or immune-mediated. It’s really important to differentiate these because the treatments are very different depending on whether this is immune-mediated versus genetic.”

Treatment Options: Transplant

Everyone diagnosed with severe AA should be seen by a transplant specialist and have human leukocyte antigens typing and donors identified “because things can change very quickly,” Groarke said. However, hematopoietic stem cell transplant isn’t for everyone. While it is often offered to patients aged < 40 years with a matched sibling donor, older adults typically take medication instead because of the higher transplant-related mortality risk.

“It’s really individualized for patients,” Groarke explained. Patients aged ≥ 40 years with profound neutropenia may be good candidates for transplantation despite their age. Younger patients with less severe disease may not require immediate transplant, she said.

Treatment Options: Medication

Groarke, who coauthored a 2023 American Society of Hematology report on inherited bone marrow failure in adults, said that horse antithymocyte globulin (ATG) and cyclosporin have been “the mainstay” of treatment for older adults with immune AA based on a 1995 Blood study. Response rates were 67% by 3 months and 70% to 80% by 1 year.

Researchers tried for years to boost responses but failed until the rise of a combination therapy that includes ATG, cyclosporin, and eltrombopag. This combination therapy has become the standard of care.

There have been questions about using ATG in patients aged > 60 years. Groarke said research supports the medication in this population. “They seem to respond equally well as younger patients,” she said.

While older patients do have more cardiac complications, Groarke said her clinic still administers ATG to them. However, “the one history that gives us some pause is a significant cardiac history.”

Disclosures for Groarke were not provided.

Immunosuppressive therapy and transplant strategies are critical in the management of immune aplastic anemia (AA), a hematologist told colleagues during a recent Association of VA Hematology/Oncology (AVAHO) webinar on rare and ultrarare blood disorders. But the first major challenge is diagnosis, said Emma M. Groarke, MD, of the National Heart, Lung, and Blood Institute at the National Institutes of Health.

According to Groarke, patients with bone marrow failure—a large category that includes AA—typically present with bone marrow hypocellularity (abnormally few cells) and reticulocytopenia (abnormally few immature blood cells). But these conditions also may be the result of other disorders, such as malignant cancer, medication-induced cytopenias, vitamin deficiencies, infection, or advanced liver disease.

After diagnosing a patient with bone marrow hypocellularity, clinicians need to consider whether the underlying etiology is immune or inherited, she said. Radiation can also cause AA, but that is not common outside chemotherapy.

“In younger patients, you have a higher threshold of suspicion for an inherited or germline disorder,” she said. “Whereas in older patients, it's more likely to be acquired or immune-mediated. It’s really important to differentiate these because the treatments are very different depending on whether this is immune-mediated versus genetic.”

Treatment Options: Transplant

Everyone diagnosed with severe AA should be seen by a transplant specialist and have human leukocyte antigens typing and donors identified “because things can change very quickly,” Groarke said. However, hematopoietic stem cell transplant isn’t for everyone. While it is often offered to patients aged < 40 years with a matched sibling donor, older adults typically take medication instead because of the higher transplant-related mortality risk.

“It’s really individualized for patients,” Groarke explained. Patients aged ≥ 40 years with profound neutropenia may be good candidates for transplantation despite their age. Younger patients with less severe disease may not require immediate transplant, she said.

Treatment Options: Medication

Groarke, who coauthored a 2023 American Society of Hematology report on inherited bone marrow failure in adults, said that horse antithymocyte globulin (ATG) and cyclosporin have been “the mainstay” of treatment for older adults with immune AA based on a 1995 Blood study. Response rates were 67% by 3 months and 70% to 80% by 1 year.

Researchers tried for years to boost responses but failed until the rise of a combination therapy that includes ATG, cyclosporin, and eltrombopag. This combination therapy has become the standard of care.

There have been questions about using ATG in patients aged > 60 years. Groarke said research supports the medication in this population. “They seem to respond equally well as younger patients,” she said.

While older patients do have more cardiac complications, Groarke said her clinic still administers ATG to them. However, “the one history that gives us some pause is a significant cardiac history.”

Disclosures for Groarke were not provided.

Acquired hemophilia A (AHA) is a rare, easily missed, and highly fatal blood disorder, a hematologist cautioned colleagues in a recent webinar sponsored by the Association of VA Hematology/Oncology (AVAHO). An autoimmune condition, patients with AHA develop antibodies against clotting factor VIII (F8). The incidence rate is estimated at 1 to 1.5 per 1 million per year, with a mortality rate as high as 22%.

“Hemostasis and inhibitor eradication are key pillars of treatment. But the way we do that may be changing as new therapies come online,” said hematologist Aaron Boothby, MD, of Fred Hutchinson Cancer Center and the University of Washington.

Keys to Diagnosis

Classic presentation of AHA is bruising and bleeding with an isolated elevated partial thromboplastin time (PTT), Boothby said: “Weld that onto your mind so that that isolated, elevated PTT doesn’t get missed. Because it often does.”

As for symptoms, it has a “unique bleeding pattern,” he said. It is different than congenital hemophilia, when it is common to see bleeding from the joint. That can also happen in AHA, Boothby said, but is “quite rare.” Instead, subcutaneous and intramuscular hematomas are more common.

One-half of AHA cases are idiopathic; the other half are linked to causes such as malignancy, autoimmune disease, pregnancy, infections, and skin disorders. Certain medications are culprits as well, and there have been unconfirmed signs of a link to COVID-19 vaccination.

Meet a Patient With AHA

AHA is more common in older patients, reaching its highest prevalence in patients aged ≥ 70 years, Boothby said. He highlighted the recent case of a 71-year-old male patient with diabetes, chronic obstructive pulmonary disease, and tonsillar squamous cell carcinoma.

The patient noted easy bruising and bleeding for the several months, “but hadn’t made too much of it.” He was not taking any anticoagulants or antiplatelet agents. At the emergency department, the patient’s hematomas were treated, and red blood cells were transfused. His hemoglobin level was low (6 g/dL), but no PTT test was performed, delaying diagnosis.

The patient returned with a bleeding in his knee and more hematomas. A false-positive lupus anticoagulant test initially misled the clinicians, but a high PTT test (120 seconds) ultimately led to the AHA diagnosis.

“If you’re worried about this diagnosis, don’t hesitate to reach out to your local hemophilia treatment center,” Boothby said. “We’re always available to help think through testing and management.”

Treatment: Stop Bleeding, Target Antibodies

The pillars of AHA treatment include working to stop the bleeding and eradicate inhibitors to remove the F8 antibodies, Boothby said. Recombinant porcine F8 can be used as a replacement therapy. Activated prothrombin complex concentrate and recombinant activated factor VII are bypassing therapy options.

First-line immunosuppression strategies include corticosteroids alone, corticosteroid and cyclophosphamide or mycophenolate mofetil, and corticosteroids and rituximab.

New Option Holds Promise

Boothby highlighted emicizumab, a bispecific antibody approved for congenital hemophilia being studied off label in AHA.

He cited a recent case where one of his patients was ultimately treated with recombinant coagulation factor VIIa to control the bleeding but steroids were discontinued due to concerns about wound healing and diabetes control. The patient received emicizumab and rituximab and had no bleeding at home for 3 weeks.

Boothby has no disclosures.

Acquired hemophilia A (AHA) is a rare, easily missed, and highly fatal blood disorder, a hematologist cautioned colleagues in a recent webinar sponsored by the Association of VA Hematology/Oncology (AVAHO). An autoimmune condition, patients with AHA develop antibodies against clotting factor VIII (F8). The incidence rate is estimated at 1 to 1.5 per 1 million per year, with a mortality rate as high as 22%.

“Hemostasis and inhibitor eradication are key pillars of treatment. But the way we do that may be changing as new therapies come online,” said hematologist Aaron Boothby, MD, of Fred Hutchinson Cancer Center and the University of Washington.

Keys to Diagnosis

Classic presentation of AHA is bruising and bleeding with an isolated elevated partial thromboplastin time (PTT), Boothby said: “Weld that onto your mind so that that isolated, elevated PTT doesn’t get missed. Because it often does.”

As for symptoms, it has a “unique bleeding pattern,” he said. It is different than congenital hemophilia, when it is common to see bleeding from the joint. That can also happen in AHA, Boothby said, but is “quite rare.” Instead, subcutaneous and intramuscular hematomas are more common.

One-half of AHA cases are idiopathic; the other half are linked to causes such as malignancy, autoimmune disease, pregnancy, infections, and skin disorders. Certain medications are culprits as well, and there have been unconfirmed signs of a link to COVID-19 vaccination.

Meet a Patient With AHA

AHA is more common in older patients, reaching its highest prevalence in patients aged ≥ 70 years, Boothby said. He highlighted the recent case of a 71-year-old male patient with diabetes, chronic obstructive pulmonary disease, and tonsillar squamous cell carcinoma.

The patient noted easy bruising and bleeding for the several months, “but hadn’t made too much of it.” He was not taking any anticoagulants or antiplatelet agents. At the emergency department, the patient’s hematomas were treated, and red blood cells were transfused. His hemoglobin level was low (6 g/dL), but no PTT test was performed, delaying diagnosis.

The patient returned with a bleeding in his knee and more hematomas. A false-positive lupus anticoagulant test initially misled the clinicians, but a high PTT test (120 seconds) ultimately led to the AHA diagnosis.

“If you’re worried about this diagnosis, don’t hesitate to reach out to your local hemophilia treatment center,” Boothby said. “We’re always available to help think through testing and management.”

Treatment: Stop Bleeding, Target Antibodies

The pillars of AHA treatment include working to stop the bleeding and eradicate inhibitors to remove the F8 antibodies, Boothby said. Recombinant porcine F8 can be used as a replacement therapy. Activated prothrombin complex concentrate and recombinant activated factor VII are bypassing therapy options.

First-line immunosuppression strategies include corticosteroids alone, corticosteroid and cyclophosphamide or mycophenolate mofetil, and corticosteroids and rituximab.

New Option Holds Promise

Boothby highlighted emicizumab, a bispecific antibody approved for congenital hemophilia being studied off label in AHA.

He cited a recent case where one of his patients was ultimately treated with recombinant coagulation factor VIIa to control the bleeding but steroids were discontinued due to concerns about wound healing and diabetes control. The patient received emicizumab and rituximab and had no bleeding at home for 3 weeks.

Boothby has no disclosures.

Acquired hemophilia A (AHA) is a rare, easily missed, and highly fatal blood disorder, a hematologist cautioned colleagues in a recent webinar sponsored by the Association of VA Hematology/Oncology (AVAHO). An autoimmune condition, patients with AHA develop antibodies against clotting factor VIII (F8). The incidence rate is estimated at 1 to 1.5 per 1 million per year, with a mortality rate as high as 22%.

“Hemostasis and inhibitor eradication are key pillars of treatment. But the way we do that may be changing as new therapies come online,” said hematologist Aaron Boothby, MD, of Fred Hutchinson Cancer Center and the University of Washington.

Keys to Diagnosis

Classic presentation of AHA is bruising and bleeding with an isolated elevated partial thromboplastin time (PTT), Boothby said: “Weld that onto your mind so that that isolated, elevated PTT doesn’t get missed. Because it often does.”

As for symptoms, it has a “unique bleeding pattern,” he said. It is different than congenital hemophilia, when it is common to see bleeding from the joint. That can also happen in AHA, Boothby said, but is “quite rare.” Instead, subcutaneous and intramuscular hematomas are more common.

One-half of AHA cases are idiopathic; the other half are linked to causes such as malignancy, autoimmune disease, pregnancy, infections, and skin disorders. Certain medications are culprits as well, and there have been unconfirmed signs of a link to COVID-19 vaccination.

Meet a Patient With AHA

AHA is more common in older patients, reaching its highest prevalence in patients aged ≥ 70 years, Boothby said. He highlighted the recent case of a 71-year-old male patient with diabetes, chronic obstructive pulmonary disease, and tonsillar squamous cell carcinoma.

The patient noted easy bruising and bleeding for the several months, “but hadn’t made too much of it.” He was not taking any anticoagulants or antiplatelet agents. At the emergency department, the patient’s hematomas were treated, and red blood cells were transfused. His hemoglobin level was low (6 g/dL), but no PTT test was performed, delaying diagnosis.

The patient returned with a bleeding in his knee and more hematomas. A false-positive lupus anticoagulant test initially misled the clinicians, but a high PTT test (120 seconds) ultimately led to the AHA diagnosis.

“If you’re worried about this diagnosis, don’t hesitate to reach out to your local hemophilia treatment center,” Boothby said. “We’re always available to help think through testing and management.”

Treatment: Stop Bleeding, Target Antibodies

The pillars of AHA treatment include working to stop the bleeding and eradicate inhibitors to remove the F8 antibodies, Boothby said. Recombinant porcine F8 can be used as a replacement therapy. Activated prothrombin complex concentrate and recombinant activated factor VII are bypassing therapy options.

First-line immunosuppression strategies include corticosteroids alone, corticosteroid and cyclophosphamide or mycophenolate mofetil, and corticosteroids and rituximab.

New Option Holds Promise

Boothby highlighted emicizumab, a bispecific antibody approved for congenital hemophilia being studied off label in AHA.

He cited a recent case where one of his patients was ultimately treated with recombinant coagulation factor VIIa to control the bleeding but steroids were discontinued due to concerns about wound healing and diabetes control. The patient received emicizumab and rituximab and had no bleeding at home for 3 weeks.

Boothby has no disclosures.

TOPLINE:

Among 401 post-9/11 veterans with retained embedded fragments, those with blast exposure (n = 361) were more likely to report dyspnea compared with unexposed veterans, though both groups reported respiratory symptoms (ie, cough, phlegm, wheeze). Veterans with blast exposure demonstrated higher forced vital capacity (FVC), total lung capacity (TLC), and diffusing capacity of carbon monoxide (DLCO) values, suggesting better lung function, while those with traumatic brain injury (TBI) showed lower lung volumes.

METHODOLOGY:

• A total of 402 veterans from the US Department of Veterans Affairs (VA) Toxic Embedded Fragment (TEF) Registry across 6 VA facilities were recruited from April 2018 through March 2021; 361 reported blast exposure, 41 did not.
• Participants completed questionnaires assessing blast exposure using the Brief Traumatic Brain Injury Screening (BTBIS), history of TBI, and respiratory symptoms and diagnoses based on the American Thoracic Society and Division of Lung Disease questionnaire.
• A total of 369 veterans underwent prebronchodilator pulmonary function testing (PFT) including spirometry, lung volumes, and diffusion capacity, as well as impulse oscillometry (IOS) testing; 33 participants recruited after March 2020 were excluded from physiologic testing due to COVID-19 pandemic restrictions.
• Primary outcomes included respiratory symptoms (cough, wheeze, dyspnea) and diagnoses (chronic obstructive pulmonary disease, asthma), while secondary outcomes included PFT and IOS measures such as forced expiratory volume in 1 second (FEV1), FVC, TLC, functional residual capacity (FRC), residual volume (RV), DLCO, and resistance and reactance parameters.

TAKEAWAY:

• Veterans with blast exposure were significantly more likely to report shortness of breath when hurrying on level ground or walking up a slight hill compared with those without blast exposure (adjusted odds ratio [aOR], 2.35; 95% CI, 1.04-5.33; P = .040).
• Blast-exposed veterans demonstrated significantly higher mean measured values for FVC (4.81 L vs 4.62 L; P = .010), TLC (6.46 L vs 6.12 L; P = .024), and DLCO (28.87 ml/min/mmHg vs 27.65 ml/min/mmHg; P = .041) compared with unexposed veterans.
• Among blast-exposed veterans, those with self-reported TBI diagnosis had significantly lower TLC (P = .04), FRC (P = .003), RV (P = .003), and RV/TLC ratio (P = .014) compared with veterans without TBI.
• No significant differences were noted between blast-exposed and unexposed groups in prevalence of cough, phlegm, wheeze, respiratory diagnoses, or IOS testing outcomes.

IN PRACTICE:

"When assessed using affirmative responses to the BTBIS to signify blast-exposure, we found few differences in blast exposed compared to unexposed veterans regarding respiratory symptoms, except for increased mild dyspnea among those with blast exposure. However, this cohort of young veterans overall expressed a high prevalence of respiratory symptoms without a similarly high prevalence of respiratory diagnoses," wrote the authors of the study.

SOURCE:

The study was led by Danielle R. Glick, Department of Veterans Affairs Medical Center, Baltimore, and Stella E. Hines, University of Maryland School of Medicine, Baltimore. It was published online May 12 in Frontiers in Public Health.

LIMITATIONS:

The study had a small sample of participants not exposed to blasts (41 vs 361 exposed), which may have limited the ability to detect small differences between groups, though the sample size provided 80% power to detect medium effect sizes. Blast exposure was assessed using self-reported responses from the BTBIS tool, which may have created exposure misclassification and obscured dose-response relationships beyond the severity analysis surrogates. The study relied on self-reported data without verification through medical records or imaging, which may have introduced recall bias. Participants were recruited exclusively from the TEF registry of veterans who sought VA care, which may not represent the broader post-9/11 veteran population.

DISCLOSURES:

This study received financial support under Department of Defense grant number W81XWH-16-2-0058 from the Congressionally Directed Medical Research Program. The study received approval from the VA Central Institutional Review Board (protocol #17-13), the US Army Medical Research and Development Command Human Research Protection Office (protocol A-19735), and local VA Research and Development Committees at the Baltimore, Gainesville, Nashville, Oklahoma City, San Antonio, and Phoenix VA Medical Centers along with their affiliated institutional review boards. No relevant conflicts of interest were disclosed by the authors. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE:

Among 401 post-9/11 veterans with retained embedded fragments, those with blast exposure (n = 361) were more likely to report dyspnea compared with unexposed veterans, though both groups reported respiratory symptoms (ie, cough, phlegm, wheeze). Veterans with blast exposure demonstrated higher forced vital capacity (FVC), total lung capacity (TLC), and diffusing capacity of carbon monoxide (DLCO) values, suggesting better lung function, while those with traumatic brain injury (TBI) showed lower lung volumes.

METHODOLOGY:

• A total of 402 veterans from the US Department of Veterans Affairs (VA) Toxic Embedded Fragment (TEF) Registry across 6 VA facilities were recruited from April 2018 through March 2021; 361 reported blast exposure, 41 did not.
• Participants completed questionnaires assessing blast exposure using the Brief Traumatic Brain Injury Screening (BTBIS), history of TBI, and respiratory symptoms and diagnoses based on the American Thoracic Society and Division of Lung Disease questionnaire.
• A total of 369 veterans underwent prebronchodilator pulmonary function testing (PFT) including spirometry, lung volumes, and diffusion capacity, as well as impulse oscillometry (IOS) testing; 33 participants recruited after March 2020 were excluded from physiologic testing due to COVID-19 pandemic restrictions.
• Primary outcomes included respiratory symptoms (cough, wheeze, dyspnea) and diagnoses (chronic obstructive pulmonary disease, asthma), while secondary outcomes included PFT and IOS measures such as forced expiratory volume in 1 second (FEV1), FVC, TLC, functional residual capacity (FRC), residual volume (RV), DLCO, and resistance and reactance parameters.

TAKEAWAY:

• Veterans with blast exposure were significantly more likely to report shortness of breath when hurrying on level ground or walking up a slight hill compared with those without blast exposure (adjusted odds ratio [aOR], 2.35; 95% CI, 1.04-5.33; P = .040).
• Blast-exposed veterans demonstrated significantly higher mean measured values for FVC (4.81 L vs 4.62 L; P = .010), TLC (6.46 L vs 6.12 L; P = .024), and DLCO (28.87 ml/min/mmHg vs 27.65 ml/min/mmHg; P = .041) compared with unexposed veterans.
• Among blast-exposed veterans, those with self-reported TBI diagnosis had significantly lower TLC (P = .04), FRC (P = .003), RV (P = .003), and RV/TLC ratio (P = .014) compared with veterans without TBI.
• No significant differences were noted between blast-exposed and unexposed groups in prevalence of cough, phlegm, wheeze, respiratory diagnoses, or IOS testing outcomes.

IN PRACTICE:

"When assessed using affirmative responses to the BTBIS to signify blast-exposure, we found few differences in blast exposed compared to unexposed veterans regarding respiratory symptoms, except for increased mild dyspnea among those with blast exposure. However, this cohort of young veterans overall expressed a high prevalence of respiratory symptoms without a similarly high prevalence of respiratory diagnoses," wrote the authors of the study.

SOURCE:

The study was led by Danielle R. Glick, Department of Veterans Affairs Medical Center, Baltimore, and Stella E. Hines, University of Maryland School of Medicine, Baltimore. It was published online May 12 in Frontiers in Public Health.

LIMITATIONS:

The study had a small sample of participants not exposed to blasts (41 vs 361 exposed), which may have limited the ability to detect small differences between groups, though the sample size provided 80% power to detect medium effect sizes. Blast exposure was assessed using self-reported responses from the BTBIS tool, which may have created exposure misclassification and obscured dose-response relationships beyond the severity analysis surrogates. The study relied on self-reported data without verification through medical records or imaging, which may have introduced recall bias. Participants were recruited exclusively from the TEF registry of veterans who sought VA care, which may not represent the broader post-9/11 veteran population.

DISCLOSURES:

This study received financial support under Department of Defense grant number W81XWH-16-2-0058 from the Congressionally Directed Medical Research Program. The study received approval from the VA Central Institutional Review Board (protocol #17-13), the US Army Medical Research and Development Command Human Research Protection Office (protocol A-19735), and local VA Research and Development Committees at the Baltimore, Gainesville, Nashville, Oklahoma City, San Antonio, and Phoenix VA Medical Centers along with their affiliated institutional review boards. No relevant conflicts of interest were disclosed by the authors. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE:

Among 401 post-9/11 veterans with retained embedded fragments, those with blast exposure (n = 361) were more likely to report dyspnea compared with unexposed veterans, though both groups reported respiratory symptoms (ie, cough, phlegm, wheeze). Veterans with blast exposure demonstrated higher forced vital capacity (FVC), total lung capacity (TLC), and diffusing capacity of carbon monoxide (DLCO) values, suggesting better lung function, while those with traumatic brain injury (TBI) showed lower lung volumes.

METHODOLOGY:

• A total of 402 veterans from the US Department of Veterans Affairs (VA) Toxic Embedded Fragment (TEF) Registry across 6 VA facilities were recruited from April 2018 through March 2021; 361 reported blast exposure, 41 did not.
• Participants completed questionnaires assessing blast exposure using the Brief Traumatic Brain Injury Screening (BTBIS), history of TBI, and respiratory symptoms and diagnoses based on the American Thoracic Society and Division of Lung Disease questionnaire.
• A total of 369 veterans underwent prebronchodilator pulmonary function testing (PFT) including spirometry, lung volumes, and diffusion capacity, as well as impulse oscillometry (IOS) testing; 33 participants recruited after March 2020 were excluded from physiologic testing due to COVID-19 pandemic restrictions.
• Primary outcomes included respiratory symptoms (cough, wheeze, dyspnea) and diagnoses (chronic obstructive pulmonary disease, asthma), while secondary outcomes included PFT and IOS measures such as forced expiratory volume in 1 second (FEV1), FVC, TLC, functional residual capacity (FRC), residual volume (RV), DLCO, and resistance and reactance parameters.

TAKEAWAY:

• Veterans with blast exposure were significantly more likely to report shortness of breath when hurrying on level ground or walking up a slight hill compared with those without blast exposure (adjusted odds ratio [aOR], 2.35; 95% CI, 1.04-5.33; P = .040).
• Blast-exposed veterans demonstrated significantly higher mean measured values for FVC (4.81 L vs 4.62 L; P = .010), TLC (6.46 L vs 6.12 L; P = .024), and DLCO (28.87 ml/min/mmHg vs 27.65 ml/min/mmHg; P = .041) compared with unexposed veterans.
• Among blast-exposed veterans, those with self-reported TBI diagnosis had significantly lower TLC (P = .04), FRC (P = .003), RV (P = .003), and RV/TLC ratio (P = .014) compared with veterans without TBI.
• No significant differences were noted between blast-exposed and unexposed groups in prevalence of cough, phlegm, wheeze, respiratory diagnoses, or IOS testing outcomes.

IN PRACTICE:

"When assessed using affirmative responses to the BTBIS to signify blast-exposure, we found few differences in blast exposed compared to unexposed veterans regarding respiratory symptoms, except for increased mild dyspnea among those with blast exposure. However, this cohort of young veterans overall expressed a high prevalence of respiratory symptoms without a similarly high prevalence of respiratory diagnoses," wrote the authors of the study.

SOURCE:

The study was led by Danielle R. Glick, Department of Veterans Affairs Medical Center, Baltimore, and Stella E. Hines, University of Maryland School of Medicine, Baltimore. It was published online May 12 in Frontiers in Public Health.

LIMITATIONS:

The study had a small sample of participants not exposed to blasts (41 vs 361 exposed), which may have limited the ability to detect small differences between groups, though the sample size provided 80% power to detect medium effect sizes. Blast exposure was assessed using self-reported responses from the BTBIS tool, which may have created exposure misclassification and obscured dose-response relationships beyond the severity analysis surrogates. The study relied on self-reported data without verification through medical records or imaging, which may have introduced recall bias. Participants were recruited exclusively from the TEF registry of veterans who sought VA care, which may not represent the broader post-9/11 veteran population.

DISCLOSURES:

This study received financial support under Department of Defense grant number W81XWH-16-2-0058 from the Congressionally Directed Medical Research Program. The study received approval from the VA Central Institutional Review Board (protocol #17-13), the US Army Medical Research and Development Command Human Research Protection Office (protocol A-19735), and local VA Research and Development Committees at the Baltimore, Gainesville, Nashville, Oklahoma City, San Antonio, and Phoenix VA Medical Centers along with their affiliated institutional review boards. No relevant conflicts of interest were disclosed by the authors. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Single maintenance and relief therapy (SMART) is underutilized in asthmatic children treated in primary care, a survey-based clinician study in Pediatrics found.

SMART uses a single inhaler combining an inhaled corticosteroid and formoterol, a rapid-acting bronchodilator. Patients use it for daily maintenance and as needed for symptom relief, which reduces flare-ups and simplifies treatment. Despite high awareness and acceptance of SMART’s efficacy and the American Academy of Pediatrics endorsement, primary care survey respondents reported that implementation of these single inhalers faces multiple roadblocks.

These barriers include insurance coverage, workflow constraints, lack of specific action plans, and resistance to switching from separate short-acting beta-agonist (SABA) therapy, according to investigators led by Allison A. King, MD, MPH, PhD, professor and Fred M. Saigh Distinguished Chair in Pediatric Research at WashU Medicine in St. Louis and director of the WashU Medicine Pediatric and Adolescent Ambulatory Research Consortium (WU PAARC).

“When I took on leadership of WU PAARC about 2 years ago, one of the first things we did was ask the community pediatricians in our network what they most needed to improve care in their own practices. SMART for asthma rose to the top of their list,” King told Medscape Medical News.

The clinical backdrop made it compelling since SMART reduces severe asthma exacerbations by about a third and is now recommended in US and international guidelines for children as young as 4 or 5, she said. “Yet most children with asthma are cared for in primary care, and we knew very little about whether and how SMART was actually being used there. We set out to understand the gap between strong evidence and everyday practice.”

The Study

Conducted during August and September 2025 among pediatric clinicians affiliated with the practice-based WU PAARC, the study invited 189 clinicians to participate. Of these, 52 responded (79% suburban practitioners), and 24 participated in semi-structured follow-up interviews.

“Our respondents skewed suburban and cared for relatively few Medicaid-insured children, so the findings may underrepresent clinicians in higher-Medicaid settings, where coverage and prior-authorization issues can play out differently,” said King. “That’s something we want to address directly in future work.”

While nearly all respondents reported routinely managing the core aspects of asthma treatment, including action plans, only 63% reported providing SMART-tailored action plans, which emerged as a key barrier across different care settings.

Two findings in particular caught the investigators’ attention: the relative absence of SMART-specific asthma action plans and the real difficulty of helping families let go of trusted SABA rescue inhalers, King said. “The pediatric context, where care is shared across parents, schools, and other caregivers, added a layer that adult studies simply do not capture.”

Offering her perspective on the study but involved in it, Santina J. Wheat, MD, MPH, physician in the Division of Family Medicine at Northwestern Medicine Delnor Hospital in Geneva, noted that while SMART is easier to use for families because there are fewer medications to worry about, the biggest barrier remains insurance approval.

“When SMART is used correctly, families run out of the medication more quickly than insurance will pay for it,” she told Medscape Medical News. Even when insurance does cover it, there are often prior authorizations associated with the medications that delay families in being able to get the medications, she said.

Standard coverage authorizations for the SMART inhalers would be helpful, said Wheat. “Additionally, we need the support of schools — training and education may be needed for the school nurses to support the children with these treatment plans.”

Single fixes will not do it, King agreed. “It takes a coordinated bundle.” On the clinician side, practical, hands-on support like practice facilitation, feedback, and brief educational outreach will help move people from belief into routine use.

On the system side, building SMART-specific asthma action plans directly into the electronic health records removes a recurring point of friction. “And because pediatric asthma care is distributed across families and schools, caregiver-facing education and clear school communication tools are essential to help everyone move away from automatic albuterol use.”

Fortunately, the appetite for change is already there. “Clinicians are not skeptical of the evidence,” King said. “This is an implementation challenge, not a debate about whether SMART works, and that is a hopeful place to start, because implementation problems are solvable with the right tools and support.”

Partnerships with professional societies are essential to moving this into national practice, King added. “SMART sits at the intersection of primary care, allergy, and pulmonology, so collaboration across those communities matters.”

This research was supported by the American Lung Association, the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Sciences, the Doris Duke Charitable Foundation, and the Children’s Discovery Institute, a collaboration between the St. Louis Children’s Hospital, its foundation, and WashU Medicine.

King reported receiving funding from the National Institutes of Health (NIH), consulting for Evernorth, and royalties from UpToDate. Coauthor James G. Krings disclosed funding from the NIH, the American Lung Association, the Patient-Centered Outcomes Research Institute, and the Doris Duke Charitable Foundation, and consulting fees or honoraria from multiple pharmaceutical companies, including, among others, AstraZeneca, GSK, Sanofi-Regeneron (manufacturers of SMART inhalers), Aerogen, and Genentech/Roche. Aimes S. James reported receiving funding from the NIH and the Barnes-Jewish Hospital Foundation. All other authors reported having no relevant financial disclosures. Wheat reported having no conflicts of interest.

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

Single maintenance and relief therapy (SMART) is underutilized in asthmatic children treated in primary care, a survey-based clinician study in Pediatrics found.

SMART uses a single inhaler combining an inhaled corticosteroid and formoterol, a rapid-acting bronchodilator. Patients use it for daily maintenance and as needed for symptom relief, which reduces flare-ups and simplifies treatment. Despite high awareness and acceptance of SMART’s efficacy and the American Academy of Pediatrics endorsement, primary care survey respondents reported that implementation of these single inhalers faces multiple roadblocks.

These barriers include insurance coverage, workflow constraints, lack of specific action plans, and resistance to switching from separate short-acting beta-agonist (SABA) therapy, according to investigators led by Allison A. King, MD, MPH, PhD, professor and Fred M. Saigh Distinguished Chair in Pediatric Research at WashU Medicine in St. Louis and director of the WashU Medicine Pediatric and Adolescent Ambulatory Research Consortium (WU PAARC).

“When I took on leadership of WU PAARC about 2 years ago, one of the first things we did was ask the community pediatricians in our network what they most needed to improve care in their own practices. SMART for asthma rose to the top of their list,” King told Medscape Medical News.

The clinical backdrop made it compelling since SMART reduces severe asthma exacerbations by about a third and is now recommended in US and international guidelines for children as young as 4 or 5, she said. “Yet most children with asthma are cared for in primary care, and we knew very little about whether and how SMART was actually being used there. We set out to understand the gap between strong evidence and everyday practice.”

The Study

Conducted during August and September 2025 among pediatric clinicians affiliated with the practice-based WU PAARC, the study invited 189 clinicians to participate. Of these, 52 responded (79% suburban practitioners), and 24 participated in semi-structured follow-up interviews.

“Our respondents skewed suburban and cared for relatively few Medicaid-insured children, so the findings may underrepresent clinicians in higher-Medicaid settings, where coverage and prior-authorization issues can play out differently,” said King. “That’s something we want to address directly in future work.”

While nearly all respondents reported routinely managing the core aspects of asthma treatment, including action plans, only 63% reported providing SMART-tailored action plans, which emerged as a key barrier across different care settings.

Two findings in particular caught the investigators’ attention: the relative absence of SMART-specific asthma action plans and the real difficulty of helping families let go of trusted SABA rescue inhalers, King said. “The pediatric context, where care is shared across parents, schools, and other caregivers, added a layer that adult studies simply do not capture.”

Offering her perspective on the study but involved in it, Santina J. Wheat, MD, MPH, physician in the Division of Family Medicine at Northwestern Medicine Delnor Hospital in Geneva, noted that while SMART is easier to use for families because there are fewer medications to worry about, the biggest barrier remains insurance approval.

“When SMART is used correctly, families run out of the medication more quickly than insurance will pay for it,” she told Medscape Medical News. Even when insurance does cover it, there are often prior authorizations associated with the medications that delay families in being able to get the medications, she said.

Standard coverage authorizations for the SMART inhalers would be helpful, said Wheat. “Additionally, we need the support of schools — training and education may be needed for the school nurses to support the children with these treatment plans.”

Single fixes will not do it, King agreed. “It takes a coordinated bundle.” On the clinician side, practical, hands-on support like practice facilitation, feedback, and brief educational outreach will help move people from belief into routine use.

On the system side, building SMART-specific asthma action plans directly into the electronic health records removes a recurring point of friction. “And because pediatric asthma care is distributed across families and schools, caregiver-facing education and clear school communication tools are essential to help everyone move away from automatic albuterol use.”

Fortunately, the appetite for change is already there. “Clinicians are not skeptical of the evidence,” King said. “This is an implementation challenge, not a debate about whether SMART works, and that is a hopeful place to start, because implementation problems are solvable with the right tools and support.”

Partnerships with professional societies are essential to moving this into national practice, King added. “SMART sits at the intersection of primary care, allergy, and pulmonology, so collaboration across those communities matters.”

This research was supported by the American Lung Association, the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Sciences, the Doris Duke Charitable Foundation, and the Children’s Discovery Institute, a collaboration between the St. Louis Children’s Hospital, its foundation, and WashU Medicine.

King reported receiving funding from the National Institutes of Health (NIH), consulting for Evernorth, and royalties from UpToDate. Coauthor James G. Krings disclosed funding from the NIH, the American Lung Association, the Patient-Centered Outcomes Research Institute, and the Doris Duke Charitable Foundation, and consulting fees or honoraria from multiple pharmaceutical companies, including, among others, AstraZeneca, GSK, Sanofi-Regeneron (manufacturers of SMART inhalers), Aerogen, and Genentech/Roche. Aimes S. James reported receiving funding from the NIH and the Barnes-Jewish Hospital Foundation. All other authors reported having no relevant financial disclosures. Wheat reported having no conflicts of interest.

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

Single maintenance and relief therapy (SMART) is underutilized in asthmatic children treated in primary care, a survey-based clinician study in Pediatrics found.

SMART uses a single inhaler combining an inhaled corticosteroid and formoterol, a rapid-acting bronchodilator. Patients use it for daily maintenance and as needed for symptom relief, which reduces flare-ups and simplifies treatment. Despite high awareness and acceptance of SMART’s efficacy and the American Academy of Pediatrics endorsement, primary care survey respondents reported that implementation of these single inhalers faces multiple roadblocks.

These barriers include insurance coverage, workflow constraints, lack of specific action plans, and resistance to switching from separate short-acting beta-agonist (SABA) therapy, according to investigators led by Allison A. King, MD, MPH, PhD, professor and Fred M. Saigh Distinguished Chair in Pediatric Research at WashU Medicine in St. Louis and director of the WashU Medicine Pediatric and Adolescent Ambulatory Research Consortium (WU PAARC).

“When I took on leadership of WU PAARC about 2 years ago, one of the first things we did was ask the community pediatricians in our network what they most needed to improve care in their own practices. SMART for asthma rose to the top of their list,” King told Medscape Medical News.

The clinical backdrop made it compelling since SMART reduces severe asthma exacerbations by about a third and is now recommended in US and international guidelines for children as young as 4 or 5, she said. “Yet most children with asthma are cared for in primary care, and we knew very little about whether and how SMART was actually being used there. We set out to understand the gap between strong evidence and everyday practice.”

The Study

Conducted during August and September 2025 among pediatric clinicians affiliated with the practice-based WU PAARC, the study invited 189 clinicians to participate. Of these, 52 responded (79% suburban practitioners), and 24 participated in semi-structured follow-up interviews.

“Our respondents skewed suburban and cared for relatively few Medicaid-insured children, so the findings may underrepresent clinicians in higher-Medicaid settings, where coverage and prior-authorization issues can play out differently,” said King. “That’s something we want to address directly in future work.”

While nearly all respondents reported routinely managing the core aspects of asthma treatment, including action plans, only 63% reported providing SMART-tailored action plans, which emerged as a key barrier across different care settings.

Two findings in particular caught the investigators’ attention: the relative absence of SMART-specific asthma action plans and the real difficulty of helping families let go of trusted SABA rescue inhalers, King said. “The pediatric context, where care is shared across parents, schools, and other caregivers, added a layer that adult studies simply do not capture.”

Offering her perspective on the study but involved in it, Santina J. Wheat, MD, MPH, physician in the Division of Family Medicine at Northwestern Medicine Delnor Hospital in Geneva, noted that while SMART is easier to use for families because there are fewer medications to worry about, the biggest barrier remains insurance approval.

“When SMART is used correctly, families run out of the medication more quickly than insurance will pay for it,” she told Medscape Medical News. Even when insurance does cover it, there are often prior authorizations associated with the medications that delay families in being able to get the medications, she said.

Standard coverage authorizations for the SMART inhalers would be helpful, said Wheat. “Additionally, we need the support of schools — training and education may be needed for the school nurses to support the children with these treatment plans.”

Single fixes will not do it, King agreed. “It takes a coordinated bundle.” On the clinician side, practical, hands-on support like practice facilitation, feedback, and brief educational outreach will help move people from belief into routine use.

On the system side, building SMART-specific asthma action plans directly into the electronic health records removes a recurring point of friction. “And because pediatric asthma care is distributed across families and schools, caregiver-facing education and clear school communication tools are essential to help everyone move away from automatic albuterol use.”

Fortunately, the appetite for change is already there. “Clinicians are not skeptical of the evidence,” King said. “This is an implementation challenge, not a debate about whether SMART works, and that is a hopeful place to start, because implementation problems are solvable with the right tools and support.”

Partnerships with professional societies are essential to moving this into national practice, King added. “SMART sits at the intersection of primary care, allergy, and pulmonology, so collaboration across those communities matters.”

This research was supported by the American Lung Association, the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Sciences, the Doris Duke Charitable Foundation, and the Children’s Discovery Institute, a collaboration between the St. Louis Children’s Hospital, its foundation, and WashU Medicine.

King reported receiving funding from the National Institutes of Health (NIH), consulting for Evernorth, and royalties from UpToDate. Coauthor James G. Krings disclosed funding from the NIH, the American Lung Association, the Patient-Centered Outcomes Research Institute, and the Doris Duke Charitable Foundation, and consulting fees or honoraria from multiple pharmaceutical companies, including, among others, AstraZeneca, GSK, Sanofi-Regeneron (manufacturers of SMART inhalers), Aerogen, and Genentech/Roche. Aimes S. James reported receiving funding from the NIH and the Barnes-Jewish Hospital Foundation. All other authors reported having no relevant financial disclosures. Wheat reported having no conflicts of interest.

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

Cognitive impairment, manual dexterity, and suboptimal peak inspiratory flow are associated with inadequate inhaler technique and poor outcomes in patients with chronic obstructive pulmonary disease (COPD), based on new data from about 500 individuals.

Despite worldwide use of handheld delivery systems in the treatment of COPD, data on how patient factors affect inhaler technique with different device types are limited, said lead author Donald A. Mahler, MD, a pulmonologist and emeritus professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

Misuse of inhalers can lead to inadequate medication delivery and an increase in COPD symptoms, the researchers noted.

In a study known as INHALE published in the Annals of the American Thoracic Society, Mahler et al examined the impact of cognitive function, manual dexterity, and inhalational ability on inhaler technique. The multicenter study population included 503 outpatients aged ≥ 60 years with smoking history of at least 10 pack-years and a diagnosis of COPD. The median age was 70 years, 55% were men, 28% were current smokers, and the mean post-bronchodilator forced expiratory volume in 1 second (FEV₁) was 46% predicted.

Participants were assessed at baseline for demographics and type of inhalers, and their spirometry and peak inspiratory flow were measured on a subsequent visit 2-21 days later. Participants were instructed not to use their inhalers prior to the second visit. At the second visit, participants were asked to use their inhalers on-site, instructed to do “as you do at home,” during which time they were observed by the researchers and critiqued on their technique via a checklist. The items included preparing the device (opening the inhaler and cap), breathing out completely, positioning teeth and lips on the mouthpiece, breathing in slowly and deeply without stopping, and holding the breath for 5-10 seconds or as long as possible.

The types of handheld devices included pressurized metered dose inhalers (60%), dry powder inhalers (59%), and slow mist inhalers (18%). Cognitive function was assessed using the Mini-Mental State Exam (MMSE), and dexterity was measured using the Functional Dexterity Test (FDT). About 10% participants met criteria for cognitive impairment (MMSE score < 24), 34.8% demonstrated nonfunctional manual dexterity (FDT > 50 seconds), and 20.5% had a suboptimal peak inspiratory flow rate (PIFr < 60 L/min).

Overall, 71% of participants met criteria for acceptable inhaler technique (four or five items satisfactory) based on the checklist.

Among 103 participants who met criteria for unacceptable inhaler technique (≥ 2 items unsatisfactory), cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFrs were significantly and independently associated with poor technique (P = .0001, P = .0152, P = .014, respectively).

The individuals with poor technique also experienced smaller improvements in lung function after using their prescribed bronchodilator medications, with an average improvement in FEV1 of 69 mL at 30 minutes after inhalation compared to 105 mL among patients with acceptable technique.

Notably, satisfactory performance on the “hold your breath” technique item was the only technique that improved acute bronchodilation compared to unsatisfactory performance, which was surprising, Mahler said. “This directive or instruction needs to be emphasized when educating patients on how to use their inhalers,” he noted.

The findings were limited by several factors including the lack of data on whether participants were instructed on proper inhaler use and possible inconsistency of assessment across the multiple study sites.

However, the results provide evidence of the importance of a patient’s cognitive function, manual dexterity, and inhalational ability on effective inhaler use and support the need for healthcare professionals to consider these factors when selecting an inhaler delivery system, said Mahler. “It is most important that patients hold their breath for as long as possible after inhaling their medication from a handheld device to optimally open their airways,” he said.

“Although algorithms are available to guide healthcare professionals for inhaler selection, one or more of these algorithms needs to be tested in clinical practice to assess whether such an approach provides additional benefit for patients with COPD,” Mahler added.

Check Technique in Advance of Inhaler Selection

Although inhalers are a cornerstone therapy for COPD, many patients’ poor technique reduces the efficacy of these devices, said Arianne K. Baldomero, MD, MS, ATSF, a pulmonologist, critical care physician, and assistant professor of medicine at the University of Minnesota in Minneapolis.

“It is crucial to determine which specific patient-related factors are independently linked to poor technique, as identifying these elements may allow targeted interventions and selection of optimal device delivery systems for high-risk patients,” said Baldomero, who was not involved in the study.

The association between cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFr and unacceptable technique are not surprising, said Baldomero. “Handheld devices demand precise mental step sequence recall, coordinated hand-finger manipulation, and sufficient physical inhalation strength to separate and deliver the medication. These results validate that baseline physiological and cognitive limitations directly impair a patient’s mechanical ability to operate standard inhalers successfully,” she said.

Consequently, inhaler prescriptions must be tailored to a patient’s physical and cognitive abilities, rather than relying on a one-size-fits-all approach, Baldomero emphasized. “Clinicians should evaluate technique, prioritizing the ‘hold your breath’ step, which was uniquely tied to significant bronchodilation benefits,” she said. For patients identified with cognitive or dexterity limitations, consider alternative delivery systems, such as nebulized therapies, she added.

The real-world rates of cognitive and dexterity impairments in COPD inhaler users are likely higher than those seen in the current study, said Baldomero. In addition, the findings were limited by a lack of data on whether patients had received prior formal device training, and a lack of data on long-term clinical outcomes, she noted. “Future research should focus on validating standard screening tools for clinics and establishing clear, evidence-based guidelines for choosing alternative delivery systems,” Baldomero said.

The study was supported by the COPD Foundation, Theravance Biopharma LLC, and Viatris. Disclosure information for the authors is available in the original study publication. Baldomero had no financial conflicts to disclose.

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

Cognitive impairment, manual dexterity, and suboptimal peak inspiratory flow are associated with inadequate inhaler technique and poor outcomes in patients with chronic obstructive pulmonary disease (COPD), based on new data from about 500 individuals.

Despite worldwide use of handheld delivery systems in the treatment of COPD, data on how patient factors affect inhaler technique with different device types are limited, said lead author Donald A. Mahler, MD, a pulmonologist and emeritus professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

Misuse of inhalers can lead to inadequate medication delivery and an increase in COPD symptoms, the researchers noted.

In a study known as INHALE published in the Annals of the American Thoracic Society, Mahler et al examined the impact of cognitive function, manual dexterity, and inhalational ability on inhaler technique. The multicenter study population included 503 outpatients aged ≥ 60 years with smoking history of at least 10 pack-years and a diagnosis of COPD. The median age was 70 years, 55% were men, 28% were current smokers, and the mean post-bronchodilator forced expiratory volume in 1 second (FEV₁) was 46% predicted.

Participants were assessed at baseline for demographics and type of inhalers, and their spirometry and peak inspiratory flow were measured on a subsequent visit 2-21 days later. Participants were instructed not to use their inhalers prior to the second visit. At the second visit, participants were asked to use their inhalers on-site, instructed to do “as you do at home,” during which time they were observed by the researchers and critiqued on their technique via a checklist. The items included preparing the device (opening the inhaler and cap), breathing out completely, positioning teeth and lips on the mouthpiece, breathing in slowly and deeply without stopping, and holding the breath for 5-10 seconds or as long as possible.

The types of handheld devices included pressurized metered dose inhalers (60%), dry powder inhalers (59%), and slow mist inhalers (18%). Cognitive function was assessed using the Mini-Mental State Exam (MMSE), and dexterity was measured using the Functional Dexterity Test (FDT). About 10% participants met criteria for cognitive impairment (MMSE score < 24), 34.8% demonstrated nonfunctional manual dexterity (FDT > 50 seconds), and 20.5% had a suboptimal peak inspiratory flow rate (PIFr < 60 L/min).

Overall, 71% of participants met criteria for acceptable inhaler technique (four or five items satisfactory) based on the checklist.

Among 103 participants who met criteria for unacceptable inhaler technique (≥ 2 items unsatisfactory), cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFrs were significantly and independently associated with poor technique (P = .0001, P = .0152, P = .014, respectively).

The individuals with poor technique also experienced smaller improvements in lung function after using their prescribed bronchodilator medications, with an average improvement in FEV1 of 69 mL at 30 minutes after inhalation compared to 105 mL among patients with acceptable technique.

Notably, satisfactory performance on the “hold your breath” technique item was the only technique that improved acute bronchodilation compared to unsatisfactory performance, which was surprising, Mahler said. “This directive or instruction needs to be emphasized when educating patients on how to use their inhalers,” he noted.

The findings were limited by several factors including the lack of data on whether participants were instructed on proper inhaler use and possible inconsistency of assessment across the multiple study sites.

However, the results provide evidence of the importance of a patient’s cognitive function, manual dexterity, and inhalational ability on effective inhaler use and support the need for healthcare professionals to consider these factors when selecting an inhaler delivery system, said Mahler. “It is most important that patients hold their breath for as long as possible after inhaling their medication from a handheld device to optimally open their airways,” he said.

“Although algorithms are available to guide healthcare professionals for inhaler selection, one or more of these algorithms needs to be tested in clinical practice to assess whether such an approach provides additional benefit for patients with COPD,” Mahler added.

Check Technique in Advance of Inhaler Selection

Although inhalers are a cornerstone therapy for COPD, many patients’ poor technique reduces the efficacy of these devices, said Arianne K. Baldomero, MD, MS, ATSF, a pulmonologist, critical care physician, and assistant professor of medicine at the University of Minnesota in Minneapolis.

“It is crucial to determine which specific patient-related factors are independently linked to poor technique, as identifying these elements may allow targeted interventions and selection of optimal device delivery systems for high-risk patients,” said Baldomero, who was not involved in the study.

The association between cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFr and unacceptable technique are not surprising, said Baldomero. “Handheld devices demand precise mental step sequence recall, coordinated hand-finger manipulation, and sufficient physical inhalation strength to separate and deliver the medication. These results validate that baseline physiological and cognitive limitations directly impair a patient’s mechanical ability to operate standard inhalers successfully,” she said.

Consequently, inhaler prescriptions must be tailored to a patient’s physical and cognitive abilities, rather than relying on a one-size-fits-all approach, Baldomero emphasized. “Clinicians should evaluate technique, prioritizing the ‘hold your breath’ step, which was uniquely tied to significant bronchodilation benefits,” she said. For patients identified with cognitive or dexterity limitations, consider alternative delivery systems, such as nebulized therapies, she added.

The real-world rates of cognitive and dexterity impairments in COPD inhaler users are likely higher than those seen in the current study, said Baldomero. In addition, the findings were limited by a lack of data on whether patients had received prior formal device training, and a lack of data on long-term clinical outcomes, she noted. “Future research should focus on validating standard screening tools for clinics and establishing clear, evidence-based guidelines for choosing alternative delivery systems,” Baldomero said.

The study was supported by the COPD Foundation, Theravance Biopharma LLC, and Viatris. Disclosure information for the authors is available in the original study publication. Baldomero had no financial conflicts to disclose.

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

Cognitive impairment, manual dexterity, and suboptimal peak inspiratory flow are associated with inadequate inhaler technique and poor outcomes in patients with chronic obstructive pulmonary disease (COPD), based on new data from about 500 individuals.

Despite worldwide use of handheld delivery systems in the treatment of COPD, data on how patient factors affect inhaler technique with different device types are limited, said lead author Donald A. Mahler, MD, a pulmonologist and emeritus professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

Misuse of inhalers can lead to inadequate medication delivery and an increase in COPD symptoms, the researchers noted.

In a study known as INHALE published in the Annals of the American Thoracic Society, Mahler et al examined the impact of cognitive function, manual dexterity, and inhalational ability on inhaler technique. The multicenter study population included 503 outpatients aged ≥ 60 years with smoking history of at least 10 pack-years and a diagnosis of COPD. The median age was 70 years, 55% were men, 28% were current smokers, and the mean post-bronchodilator forced expiratory volume in 1 second (FEV₁) was 46% predicted.

Participants were assessed at baseline for demographics and type of inhalers, and their spirometry and peak inspiratory flow were measured on a subsequent visit 2-21 days later. Participants were instructed not to use their inhalers prior to the second visit. At the second visit, participants were asked to use their inhalers on-site, instructed to do “as you do at home,” during which time they were observed by the researchers and critiqued on their technique via a checklist. The items included preparing the device (opening the inhaler and cap), breathing out completely, positioning teeth and lips on the mouthpiece, breathing in slowly and deeply without stopping, and holding the breath for 5-10 seconds or as long as possible.

The types of handheld devices included pressurized metered dose inhalers (60%), dry powder inhalers (59%), and slow mist inhalers (18%). Cognitive function was assessed using the Mini-Mental State Exam (MMSE), and dexterity was measured using the Functional Dexterity Test (FDT). About 10% participants met criteria for cognitive impairment (MMSE score < 24), 34.8% demonstrated nonfunctional manual dexterity (FDT > 50 seconds), and 20.5% had a suboptimal peak inspiratory flow rate (PIFr < 60 L/min).

Overall, 71% of participants met criteria for acceptable inhaler technique (four or five items satisfactory) based on the checklist.

Among 103 participants who met criteria for unacceptable inhaler technique (≥ 2 items unsatisfactory), cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFrs were significantly and independently associated with poor technique (P = .0001, P = .0152, P = .014, respectively).

The individuals with poor technique also experienced smaller improvements in lung function after using their prescribed bronchodilator medications, with an average improvement in FEV1 of 69 mL at 30 minutes after inhalation compared to 105 mL among patients with acceptable technique.

Notably, satisfactory performance on the “hold your breath” technique item was the only technique that improved acute bronchodilation compared to unsatisfactory performance, which was surprising, Mahler said. “This directive or instruction needs to be emphasized when educating patients on how to use their inhalers,” he noted.

The findings were limited by several factors including the lack of data on whether participants were instructed on proper inhaler use and possible inconsistency of assessment across the multiple study sites.

However, the results provide evidence of the importance of a patient’s cognitive function, manual dexterity, and inhalational ability on effective inhaler use and support the need for healthcare professionals to consider these factors when selecting an inhaler delivery system, said Mahler. “It is most important that patients hold their breath for as long as possible after inhaling their medication from a handheld device to optimally open their airways,” he said.

“Although algorithms are available to guide healthcare professionals for inhaler selection, one or more of these algorithms needs to be tested in clinical practice to assess whether such an approach provides additional benefit for patients with COPD,” Mahler added.

Check Technique in Advance of Inhaler Selection

Although inhalers are a cornerstone therapy for COPD, many patients’ poor technique reduces the efficacy of these devices, said Arianne K. Baldomero, MD, MS, ATSF, a pulmonologist, critical care physician, and assistant professor of medicine at the University of Minnesota in Minneapolis.

“It is crucial to determine which specific patient-related factors are independently linked to poor technique, as identifying these elements may allow targeted interventions and selection of optimal device delivery systems for high-risk patients,” said Baldomero, who was not involved in the study.

The association between cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFr and unacceptable technique are not surprising, said Baldomero. “Handheld devices demand precise mental step sequence recall, coordinated hand-finger manipulation, and sufficient physical inhalation strength to separate and deliver the medication. These results validate that baseline physiological and cognitive limitations directly impair a patient’s mechanical ability to operate standard inhalers successfully,” she said.

Consequently, inhaler prescriptions must be tailored to a patient’s physical and cognitive abilities, rather than relying on a one-size-fits-all approach, Baldomero emphasized. “Clinicians should evaluate technique, prioritizing the ‘hold your breath’ step, which was uniquely tied to significant bronchodilation benefits,” she said. For patients identified with cognitive or dexterity limitations, consider alternative delivery systems, such as nebulized therapies, she added.

The real-world rates of cognitive and dexterity impairments in COPD inhaler users are likely higher than those seen in the current study, said Baldomero. In addition, the findings were limited by a lack of data on whether patients had received prior formal device training, and a lack of data on long-term clinical outcomes, she noted. “Future research should focus on validating standard screening tools for clinics and establishing clear, evidence-based guidelines for choosing alternative delivery systems,” Baldomero said.

The study was supported by the COPD Foundation, Theravance Biopharma LLC, and Viatris. Disclosure information for the authors is available in the original study publication. Baldomero had no financial conflicts to disclose.

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

The FDA has approved gedatolisib (Revtorpyk, Celcuity) plus fulvestrant, with or without palbociclib, for patients with HR-positive, HER2-negative locally advanced or metastatic breast cancer without a PIK3CA mutation detected following progression on or after treatment with at least 1 line of endocrine therapy in the metastatic setting.

Gedatolisib is a multitarget inhibitor of the PI3K/AKT/mTOR (PAM) pathway, a key oncogenic driver of HR-positive, HER2-negative breast cancer that contributes to treatment resistance. While previously approved medications target single components of the pathway, gedatolisib blocks PI3K and mTOR together, leading to more comprehensive suppression, which may in turn help restore sensitivity to endocrine therapy and anti-CDK4/6 inhibition.

Approval was based on the VIKTORIA-1 trial, which randomly assigned 392 patients evenly to either gedatolisib, palbociclib, and fulvestrant (gedatolisib triplet); gedatolisib plus fulvestrant (gedatolisib doublet); or fulvestrant alone.

Median progression-free survival, the major efficacy outcome, was 9.3 months in the gedatolisib-triplet group, 7.4 months in the gedatolisib-doublet arm, and 2 months with fulvestrant monotherapy. Overall survival data were not yet mature.

In a paper published in the Journal of Clinical Oncology in March, the investigators acknowledged that fulvestrant monotherapy is no longer standard of care in the second line after anti-CDK4/6 and aromatase inhibitor failure, and that it was chosen as a comparator to meet regulatory requirements.

Still, they said the median progression-free survival in the triplet arm is “among the longest reported for a chemotherapy-free second- to third-line regimen in a phase III trial.”

Grade 3 or higher treatment-related adverse events in the triplet and doublet groups included neutropenia (62.3%, 0.8%), stomatitis (19.2%, 12.3%), rash (4.6%, 5.4%), hyperglycemia (2.3%, 2.3%), and diarrhea (1.5%, 0.8%). Overall, 2.3% of triplet and 3.1% of doublet patients stopped treatment due to adverse events. There were two treatment-related deaths in the triplet arm, one from pneumonia and the other from liver failure.

In June, Celcuity reported similarly favorable survival outcomes among 350 patients in VIKTORIA-1 who had PIK3CA mutations. Median progression-free survival was over 11 months with both the gedatolisib triplet and doublet vs 5.6 months with alpelisib plus fulvestrant, which was the comparator in the cohort with PIK3CA mutations.

The company said it planned to submit a supplemental application to the FDA for approval in patients with PIK3CA mutations.

The recommended dosage for gedatolisib is 180 mg as an intravenous infusion once weekly on days 1, 8, and 15 of every 28-day cycle, in combination with fulvestrant, with or without palbociclib, until disease progression or unacceptable toxicity.

M. Alexander Otto is a physician assistant and award-winning journalist. He is also an MIT science journalism fellow. Email: aotto@medscape.net

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

The FDA has approved gedatolisib (Revtorpyk, Celcuity) plus fulvestrant, with or without palbociclib, for patients with HR-positive, HER2-negative locally advanced or metastatic breast cancer without a PIK3CA mutation detected following progression on or after treatment with at least 1 line of endocrine therapy in the metastatic setting.

Gedatolisib is a multitarget inhibitor of the PI3K/AKT/mTOR (PAM) pathway, a key oncogenic driver of HR-positive, HER2-negative breast cancer that contributes to treatment resistance. While previously approved medications target single components of the pathway, gedatolisib blocks PI3K and mTOR together, leading to more comprehensive suppression, which may in turn help restore sensitivity to endocrine therapy and anti-CDK4/6 inhibition.

Approval was based on the VIKTORIA-1 trial, which randomly assigned 392 patients evenly to either gedatolisib, palbociclib, and fulvestrant (gedatolisib triplet); gedatolisib plus fulvestrant (gedatolisib doublet); or fulvestrant alone.

Median progression-free survival, the major efficacy outcome, was 9.3 months in the gedatolisib-triplet group, 7.4 months in the gedatolisib-doublet arm, and 2 months with fulvestrant monotherapy. Overall survival data were not yet mature.

In a paper published in the Journal of Clinical Oncology in March, the investigators acknowledged that fulvestrant monotherapy is no longer standard of care in the second line after anti-CDK4/6 and aromatase inhibitor failure, and that it was chosen as a comparator to meet regulatory requirements.

Still, they said the median progression-free survival in the triplet arm is “among the longest reported for a chemotherapy-free second- to third-line regimen in a phase III trial.”

Grade 3 or higher treatment-related adverse events in the triplet and doublet groups included neutropenia (62.3%, 0.8%), stomatitis (19.2%, 12.3%), rash (4.6%, 5.4%), hyperglycemia (2.3%, 2.3%), and diarrhea (1.5%, 0.8%). Overall, 2.3% of triplet and 3.1% of doublet patients stopped treatment due to adverse events. There were two treatment-related deaths in the triplet arm, one from pneumonia and the other from liver failure.

In June, Celcuity reported similarly favorable survival outcomes among 350 patients in VIKTORIA-1 who had PIK3CA mutations. Median progression-free survival was over 11 months with both the gedatolisib triplet and doublet vs 5.6 months with alpelisib plus fulvestrant, which was the comparator in the cohort with PIK3CA mutations.

The company said it planned to submit a supplemental application to the FDA for approval in patients with PIK3CA mutations.

The recommended dosage for gedatolisib is 180 mg as an intravenous infusion once weekly on days 1, 8, and 15 of every 28-day cycle, in combination with fulvestrant, with or without palbociclib, until disease progression or unacceptable toxicity.

M. Alexander Otto is a physician assistant and award-winning journalist. He is also an MIT science journalism fellow. Email: aotto@medscape.net

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

The FDA has approved gedatolisib (Revtorpyk, Celcuity) plus fulvestrant, with or without palbociclib, for patients with HR-positive, HER2-negative locally advanced or metastatic breast cancer without a PIK3CA mutation detected following progression on or after treatment with at least 1 line of endocrine therapy in the metastatic setting.

Gedatolisib is a multitarget inhibitor of the PI3K/AKT/mTOR (PAM) pathway, a key oncogenic driver of HR-positive, HER2-negative breast cancer that contributes to treatment resistance. While previously approved medications target single components of the pathway, gedatolisib blocks PI3K and mTOR together, leading to more comprehensive suppression, which may in turn help restore sensitivity to endocrine therapy and anti-CDK4/6 inhibition.

Approval was based on the VIKTORIA-1 trial, which randomly assigned 392 patients evenly to either gedatolisib, palbociclib, and fulvestrant (gedatolisib triplet); gedatolisib plus fulvestrant (gedatolisib doublet); or fulvestrant alone.

Median progression-free survival, the major efficacy outcome, was 9.3 months in the gedatolisib-triplet group, 7.4 months in the gedatolisib-doublet arm, and 2 months with fulvestrant monotherapy. Overall survival data were not yet mature.

In a paper published in the Journal of Clinical Oncology in March, the investigators acknowledged that fulvestrant monotherapy is no longer standard of care in the second line after anti-CDK4/6 and aromatase inhibitor failure, and that it was chosen as a comparator to meet regulatory requirements.

Still, they said the median progression-free survival in the triplet arm is “among the longest reported for a chemotherapy-free second- to third-line regimen in a phase III trial.”

Grade 3 or higher treatment-related adverse events in the triplet and doublet groups included neutropenia (62.3%, 0.8%), stomatitis (19.2%, 12.3%), rash (4.6%, 5.4%), hyperglycemia (2.3%, 2.3%), and diarrhea (1.5%, 0.8%). Overall, 2.3% of triplet and 3.1% of doublet patients stopped treatment due to adverse events. There were two treatment-related deaths in the triplet arm, one from pneumonia and the other from liver failure.

In June, Celcuity reported similarly favorable survival outcomes among 350 patients in VIKTORIA-1 who had PIK3CA mutations. Median progression-free survival was over 11 months with both the gedatolisib triplet and doublet vs 5.6 months with alpelisib plus fulvestrant, which was the comparator in the cohort with PIK3CA mutations.

The company said it planned to submit a supplemental application to the FDA for approval in patients with PIK3CA mutations.

The recommended dosage for gedatolisib is 180 mg as an intravenous infusion once weekly on days 1, 8, and 15 of every 28-day cycle, in combination with fulvestrant, with or without palbociclib, until disease progression or unacceptable toxicity.

M. Alexander Otto is a physician assistant and award-winning journalist. He is also an MIT science journalism fellow. Email: aotto@medscape.net

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

This transcript has been edited for clarity.

Hi. My name is Dr Shikha Jain. I am a gastrointestinal medical oncologist at the University of Illinois Cancer Center, and also the founder of the nonprofit Women in Medicine. I’m here to talk to you today about some of the myths that we hear around food and diet and how it can impact cancer.

One of the most common myths that I hear in my clinic all the time is that sugar feeds cancer, and I can tell you that that is categorically not true. One of the reasons people sometimes think that is because a scan called a PET scan does capture cells that are rapidly replicating, and those rapidly replicating cells ingest sugar. Oftentimes, people think that because the PET scan is lighting up where those cells are rapidly replicating, the cancer is actually eating sugar.

That is not the way it works. I have patients who’ve tried to cut sugar completely out of their diets thinking it’s going to help them, and in actuality, it doesn’t help. In some situations, especially when you’re having nausea or feeling uncomfortable or having a stomach upset, sometimes sugar can make you feel better if that is what you’re craving at the time and you’re not really craving other foods.

I strongly recommend you eat a healthy diet. You don’t need to overdose on the sugar, and especially if you have diabetes, make sure you’re managing your sugar. Sugar does not feed cancer, so please do not cut sugar completely out of your diet because it won’t help you treat cancer, nor will it help you prevent cancer.

Another very common myth that I hear is talking about things like superfoods or things that might prevent cancer because they are considered to be antioxidants and kill off cancer cells. We know as oncologists that there are many different types of foods that can actually cause cancer. For example, if you eat a diet high in processed meats or high in red meat or processed foods in general, if you’re eating some of the candies, and some of the things that people use to quit smoking have nicotine and things in them.

We know smoking is very bad for cancer. Alcohol in excess can be very damaging to the liver and the pancreas and can also cause kidney cancer or bladder cancer. Those are all things from your diet that you can remove or avoid to help you stay healthy and prevent diagnosis of cancer.

For things like vitamin supplements — I hear often about vitamin C and about turmeric and other types of foods that might help prevent cancer — there are no data currently that show any of those foods prevent cancer. There is some evidence that turmeric can be an anti-inflammatory, so some people do take turmeric in small doses or in their food as an anti-inflammatory agent, and there’s nothing wrong with that. Again, you don’t want to take too much because too much of anything can be dangerous.

People also ask me about green tea because green teas are seen as a very healthy option for you to be drinking. Green tea can be healthy, and it can be good. It can be a good thing for you to drink occasionally, but what people don’t understand or know is that too much green tea can thin your blood and put you at a higher risk for bleeding.

Any sort of thing that you’re ingesting, make sure that you talk to your doctor so they understand exactly what you’re taking, and if there’s any possibility that it might cause any complications that you may not be aware of.

The other thing I tell all of my patients is that I believe in holistic care. I believe in healthy eating. I believe in diet and exercise as ways to stay healthy. I also believe that you need to make sure that you talk to your care team about what vitamins, what supplements, what you’re putting into your body. Because what some people don’t realize, especially if you’re on any chemotherapy or systemic therapies, some of the supplements that you might take might interact with some of the systemic therapies.

For example, if you’re on a chemotherapy agent and the supplement that you’re taking actually blocks absorption of that chemotherapy agent, it may not be as effective, or it could make it more toxic. You have to be careful that whatever you’re taking, you talk to your doctor and the pharmacy team to make sure that it’s not interacting in a negative way with the medications that you’re taking as prescribed for your cancer.

I think many people don’t realize how much exercise can impact and positively impact your life if you’re going through a cancer diagnosis. We know that exercise helps prevent heart disease and helps keep us healthy overall, but there’s studies that have shown that exercise during and after receiving treatment for your cancer can prolong your life almost as much as some standard therapies.

If your patient is taking standard therapy and feeling a little sluggish, that is completely understandable, but adding exercise into their diet can be a really impactful way to keep healthy and stay alive longer. There are many different ways to take supplements, take holistic care, and take good care of oneself.

Just make sure you’re talking about what is safe and what is not. You would not believe how many patients come to me with supplements or over-the-counter vitamins. I share stories with them of patients who took some of these supplements and, because they aren’t regulated by the FDA, some of those patients actually ended up in liver failure.

I had a patient when I was in training who took a supplement as it was “prescribed” or as it was listed on the bottle. She ended up needing a liver transplant with no other medical problems, and she was very young. Again, many of these supplements can be dangerous if they’re not taken properly and if they’re not monitored by a doctor.

The final thing I want to say that I think is so important is that doctors and patients are a team. We don’t know what happens when the patient goes home at the end of the day. We can give recommendations based on evidence and science, and our goal is to help keep you healthy, stay healthy, and stay alive as long as possible. In order to do that, we need to have an open and honest discussion, there needs to be shared decision-making, and we need to make sure the decisions being made are informed and are based on good science and evidence.

Be careful when there is a celebrity or somebody online trying to sell you a supplement, because oftentimes they have a secondary gain. They might be making money from the supplement, or they might have a brand deal with them. Patients need to be really cautious when people who aren’t their doctor are telling them different supplements and holistic things to take, because they may be selling these things for some secondary gain for themselves that doesn’t actually benefit the patient. It doesn’t mean that they’re bad people. It doesn’t mean that they’re malicious people. What it means is they have a reason for what they’re trying to sell, and your patients just need to make sure that they're thinking very carefully about what goes into their bodies.

Those are very common sources of myths about diet and exercise. I hope that you have a good doctor-patient relationship and are able to talk about these things; come up with exceptional science- and evidence-based, holistic ways to manage medical care; and find great ways to have a partnership with your care team so that the patient feels comfortable with the outcomes.

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

This transcript has been edited for clarity.

Hi. My name is Dr Shikha Jain. I am a gastrointestinal medical oncologist at the University of Illinois Cancer Center, and also the founder of the nonprofit Women in Medicine. I’m here to talk to you today about some of the myths that we hear around food and diet and how it can impact cancer.

One of the most common myths that I hear in my clinic all the time is that sugar feeds cancer, and I can tell you that that is categorically not true. One of the reasons people sometimes think that is because a scan called a PET scan does capture cells that are rapidly replicating, and those rapidly replicating cells ingest sugar. Oftentimes, people think that because the PET scan is lighting up where those cells are rapidly replicating, the cancer is actually eating sugar.

That is not the way it works. I have patients who’ve tried to cut sugar completely out of their diets thinking it’s going to help them, and in actuality, it doesn’t help. In some situations, especially when you’re having nausea or feeling uncomfortable or having a stomach upset, sometimes sugar can make you feel better if that is what you’re craving at the time and you’re not really craving other foods.

I strongly recommend you eat a healthy diet. You don’t need to overdose on the sugar, and especially if you have diabetes, make sure you’re managing your sugar. Sugar does not feed cancer, so please do not cut sugar completely out of your diet because it won’t help you treat cancer, nor will it help you prevent cancer.

Another very common myth that I hear is talking about things like superfoods or things that might prevent cancer because they are considered to be antioxidants and kill off cancer cells. We know as oncologists that there are many different types of foods that can actually cause cancer. For example, if you eat a diet high in processed meats or high in red meat or processed foods in general, if you’re eating some of the candies, and some of the things that people use to quit smoking have nicotine and things in them.

We know smoking is very bad for cancer. Alcohol in excess can be very damaging to the liver and the pancreas and can also cause kidney cancer or bladder cancer. Those are all things from your diet that you can remove or avoid to help you stay healthy and prevent diagnosis of cancer.

For things like vitamin supplements — I hear often about vitamin C and about turmeric and other types of foods that might help prevent cancer — there are no data currently that show any of those foods prevent cancer. There is some evidence that turmeric can be an anti-inflammatory, so some people do take turmeric in small doses or in their food as an anti-inflammatory agent, and there’s nothing wrong with that. Again, you don’t want to take too much because too much of anything can be dangerous.

People also ask me about green tea because green teas are seen as a very healthy option for you to be drinking. Green tea can be healthy, and it can be good. It can be a good thing for you to drink occasionally, but what people don’t understand or know is that too much green tea can thin your blood and put you at a higher risk for bleeding.

Any sort of thing that you’re ingesting, make sure that you talk to your doctor so they understand exactly what you’re taking, and if there’s any possibility that it might cause any complications that you may not be aware of.

The other thing I tell all of my patients is that I believe in holistic care. I believe in healthy eating. I believe in diet and exercise as ways to stay healthy. I also believe that you need to make sure that you talk to your care team about what vitamins, what supplements, what you’re putting into your body. Because what some people don’t realize, especially if you’re on any chemotherapy or systemic therapies, some of the supplements that you might take might interact with some of the systemic therapies.

For example, if you’re on a chemotherapy agent and the supplement that you’re taking actually blocks absorption of that chemotherapy agent, it may not be as effective, or it could make it more toxic. You have to be careful that whatever you’re taking, you talk to your doctor and the pharmacy team to make sure that it’s not interacting in a negative way with the medications that you’re taking as prescribed for your cancer.

I think many people don’t realize how much exercise can impact and positively impact your life if you’re going through a cancer diagnosis. We know that exercise helps prevent heart disease and helps keep us healthy overall, but there’s studies that have shown that exercise during and after receiving treatment for your cancer can prolong your life almost as much as some standard therapies.

If your patient is taking standard therapy and feeling a little sluggish, that is completely understandable, but adding exercise into their diet can be a really impactful way to keep healthy and stay alive longer. There are many different ways to take supplements, take holistic care, and take good care of oneself.

Just make sure you’re talking about what is safe and what is not. You would not believe how many patients come to me with supplements or over-the-counter vitamins. I share stories with them of patients who took some of these supplements and, because they aren’t regulated by the FDA, some of those patients actually ended up in liver failure.

I had a patient when I was in training who took a supplement as it was “prescribed” or as it was listed on the bottle. She ended up needing a liver transplant with no other medical problems, and she was very young. Again, many of these supplements can be dangerous if they’re not taken properly and if they’re not monitored by a doctor.

The final thing I want to say that I think is so important is that doctors and patients are a team. We don’t know what happens when the patient goes home at the end of the day. We can give recommendations based on evidence and science, and our goal is to help keep you healthy, stay healthy, and stay alive as long as possible. In order to do that, we need to have an open and honest discussion, there needs to be shared decision-making, and we need to make sure the decisions being made are informed and are based on good science and evidence.

Be careful when there is a celebrity or somebody online trying to sell you a supplement, because oftentimes they have a secondary gain. They might be making money from the supplement, or they might have a brand deal with them. Patients need to be really cautious when people who aren’t their doctor are telling them different supplements and holistic things to take, because they may be selling these things for some secondary gain for themselves that doesn’t actually benefit the patient. It doesn’t mean that they’re bad people. It doesn’t mean that they’re malicious people. What it means is they have a reason for what they’re trying to sell, and your patients just need to make sure that they're thinking very carefully about what goes into their bodies.

Those are very common sources of myths about diet and exercise. I hope that you have a good doctor-patient relationship and are able to talk about these things; come up with exceptional science- and evidence-based, holistic ways to manage medical care; and find great ways to have a partnership with your care team so that the patient feels comfortable with the outcomes.

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

This transcript has been edited for clarity.

Hi. My name is Dr Shikha Jain. I am a gastrointestinal medical oncologist at the University of Illinois Cancer Center, and also the founder of the nonprofit Women in Medicine. I’m here to talk to you today about some of the myths that we hear around food and diet and how it can impact cancer.

One of the most common myths that I hear in my clinic all the time is that sugar feeds cancer, and I can tell you that that is categorically not true. One of the reasons people sometimes think that is because a scan called a PET scan does capture cells that are rapidly replicating, and those rapidly replicating cells ingest sugar. Oftentimes, people think that because the PET scan is lighting up where those cells are rapidly replicating, the cancer is actually eating sugar.

That is not the way it works. I have patients who’ve tried to cut sugar completely out of their diets thinking it’s going to help them, and in actuality, it doesn’t help. In some situations, especially when you’re having nausea or feeling uncomfortable or having a stomach upset, sometimes sugar can make you feel better if that is what you’re craving at the time and you’re not really craving other foods.

I strongly recommend you eat a healthy diet. You don’t need to overdose on the sugar, and especially if you have diabetes, make sure you’re managing your sugar. Sugar does not feed cancer, so please do not cut sugar completely out of your diet because it won’t help you treat cancer, nor will it help you prevent cancer.

Another very common myth that I hear is talking about things like superfoods or things that might prevent cancer because they are considered to be antioxidants and kill off cancer cells. We know as oncologists that there are many different types of foods that can actually cause cancer. For example, if you eat a diet high in processed meats or high in red meat or processed foods in general, if you’re eating some of the candies, and some of the things that people use to quit smoking have nicotine and things in them.

We know smoking is very bad for cancer. Alcohol in excess can be very damaging to the liver and the pancreas and can also cause kidney cancer or bladder cancer. Those are all things from your diet that you can remove or avoid to help you stay healthy and prevent diagnosis of cancer.

For things like vitamin supplements — I hear often about vitamin C and about turmeric and other types of foods that might help prevent cancer — there are no data currently that show any of those foods prevent cancer. There is some evidence that turmeric can be an anti-inflammatory, so some people do take turmeric in small doses or in their food as an anti-inflammatory agent, and there’s nothing wrong with that. Again, you don’t want to take too much because too much of anything can be dangerous.

People also ask me about green tea because green teas are seen as a very healthy option for you to be drinking. Green tea can be healthy, and it can be good. It can be a good thing for you to drink occasionally, but what people don’t understand or know is that too much green tea can thin your blood and put you at a higher risk for bleeding.

Any sort of thing that you’re ingesting, make sure that you talk to your doctor so they understand exactly what you’re taking, and if there’s any possibility that it might cause any complications that you may not be aware of.

The other thing I tell all of my patients is that I believe in holistic care. I believe in healthy eating. I believe in diet and exercise as ways to stay healthy. I also believe that you need to make sure that you talk to your care team about what vitamins, what supplements, what you’re putting into your body. Because what some people don’t realize, especially if you’re on any chemotherapy or systemic therapies, some of the supplements that you might take might interact with some of the systemic therapies.

For example, if you’re on a chemotherapy agent and the supplement that you’re taking actually blocks absorption of that chemotherapy agent, it may not be as effective, or it could make it more toxic. You have to be careful that whatever you’re taking, you talk to your doctor and the pharmacy team to make sure that it’s not interacting in a negative way with the medications that you’re taking as prescribed for your cancer.

I think many people don’t realize how much exercise can impact and positively impact your life if you’re going through a cancer diagnosis. We know that exercise helps prevent heart disease and helps keep us healthy overall, but there’s studies that have shown that exercise during and after receiving treatment for your cancer can prolong your life almost as much as some standard therapies.

If your patient is taking standard therapy and feeling a little sluggish, that is completely understandable, but adding exercise into their diet can be a really impactful way to keep healthy and stay alive longer. There are many different ways to take supplements, take holistic care, and take good care of oneself.

Just make sure you’re talking about what is safe and what is not. You would not believe how many patients come to me with supplements or over-the-counter vitamins. I share stories with them of patients who took some of these supplements and, because they aren’t regulated by the FDA, some of those patients actually ended up in liver failure.

I had a patient when I was in training who took a supplement as it was “prescribed” or as it was listed on the bottle. She ended up needing a liver transplant with no other medical problems, and she was very young. Again, many of these supplements can be dangerous if they’re not taken properly and if they’re not monitored by a doctor.

The final thing I want to say that I think is so important is that doctors and patients are a team. We don’t know what happens when the patient goes home at the end of the day. We can give recommendations based on evidence and science, and our goal is to help keep you healthy, stay healthy, and stay alive as long as possible. In order to do that, we need to have an open and honest discussion, there needs to be shared decision-making, and we need to make sure the decisions being made are informed and are based on good science and evidence.

Be careful when there is a celebrity or somebody online trying to sell you a supplement, because oftentimes they have a secondary gain. They might be making money from the supplement, or they might have a brand deal with them. Patients need to be really cautious when people who aren’t their doctor are telling them different supplements and holistic things to take, because they may be selling these things for some secondary gain for themselves that doesn’t actually benefit the patient. It doesn’t mean that they’re bad people. It doesn’t mean that they’re malicious people. What it means is they have a reason for what they’re trying to sell, and your patients just need to make sure that they're thinking very carefully about what goes into their bodies.

Those are very common sources of myths about diet and exercise. I hope that you have a good doctor-patient relationship and are able to talk about these things; come up with exceptional science- and evidence-based, holistic ways to manage medical care; and find great ways to have a partnership with your care team so that the patient feels comfortable with the outcomes.

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

Gulf War veterans continue to report significantly higher rates of chronic physical and mental health conditions than their counterparts who did not deploy, according to a new analysis of data from an ongoing cohort study.

Veterans had higher rates in 22 of 47 (47%) self-reported medical conditions compared with nondeployed veterans of the same era, reported US Department of Veterans Affairs (VA) Director of Surveillance Military Environment Exposures for Health Outcomes Military Exposures Erin K. Dursa, PhD, MPH, et al in the Journal of Occupational and Environmental Medicine.

The conditions include chronic fatigue syndrome (13.7% vs 6.2%, respectively; adjusted odds ratio [aOR], 2.44), fibromyalgia (7.5% vs 4.2%, respectively; aOR, 2.05), and irritable bowel syndrome (20.8% vs 13.1%, respectively; aOR, 1.73), all of which are considered key components of Gulf War Illness (GWI), or Gulf War Syndrome. The differences were statistically significant.

“This is still happening. They're still sick with the very same things they’ve had for 34 to 35 years,” Robert Haley, MD, professor of medicine at the University of Texas Southwestern Medical Center in Dallas, told Federal Practitioner in an interview. Haley, who has studied GWI for decades, was familiar with the findings but not involved in the new research.

The US deployed nearly 700,000 troops during the Gulf War. Many troops began reporting chronic illness following deployment, during which some were exposed to oil well fires, nerve agents, pesticides, depleted uranium, and other hazards. An estimated 150,000 troops became sick, Haley said.

“Our group and a couple others started very quickly finding evidence that it was a real illness,” he said. “It was physical, not psychological.”

According to the VA, GWI encompasses chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, and undiagnosed illnesses with symptoms such as abnormal weight loss, fatigue, cardiovascular signs, and muscle and joint pain.

Seeking an Explanation

Research links GWI to exposure to toxic sarin gas, a nerve agent used by Iraq, according to Haley. “It’s analogous to pesticide poisoning,” he said.

Other exposures may play a role, Haley said, but he believes sarin gas is the “major cause.” Sarin gas damages mitochondria within cells, causing them to produce less energy. The actual mechanism, however, remains unknown.

“We're getting real[ly] close to the answer, but we’re not there yet,” Haley said.

A 2000 study reported survey results from 15,000 Gulf War veterans and 15,000 nondeployed counterparts. The deployed veterans had a “higher prevalence of medical conditions, symptoms, functional impairment, and healthcare utilization than Gulf Era veterans.”

The new data, compiled between 2024 and 2025, represent the Gulf War Era cohort study’s fourth follow-up. Researchers surveyed 6888 Gulf War veterans and 5489 nondeployed veterans from the same era (response rate, 46.8%). The Gulf War veterans were 79.9% male; 73.1% White, 20.0% Black, 4.4% Hispanic, and 2.6% identified as another race or ethnicity. Most served in the Army (64.3%), and most were aged 17-25 (37.5%) or 26-32 (29.5%) years at deployment.

The nondeployed veteran group had similar demographics, although the cohort was older. In addition to chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, conditions that were significantly more common in Gulf War veterans than in nondeployed veterans included chronic obstructive pulmonary disease (aOR, 1.62), gastritis (aOR, 1.54), dermatitis (aOR, 1.45), bipolar or manic depression (aOR, 1.45), traumatic brain injury (aOR, 1.43), depression (aOR, 1.38), and alcohol or drug dependence (aOR, 1.36). The differences were statistically significant.

Multiple sclerosis (aOR, 0.42) was significantly less likely to be reported among Gulf War veterans.

The most common conditions reported overall by Gulf War veterans were hypertension (59.9%), sleep apnea (50.8%), arthritis not specified (41.9%), and depression (40.6%).

Affirming Reality

In an interview with Federal Practitioner, Beatrice Golomb, MD, PhD, a professor of medicine at the University of California San Diego and former VA staff physician who studies GWI, noted that researchers adjusted their analyses for body mass index (BMI), although “multiple studies show that weight gain is a metabolic feature of Gulf War Illness.”

This matters, Golomb said, because “if veterans develop increased BMI, and if that increase in BMI then contributes to things like diabetes, heart disease, and other outcomes, then adjusting for BMI will reduce the ability to see the causally-induced problems. For that reason, some problems are likely understated in this article.”

However, Golomb, who was not involved in the study, said the new research “supports findings from earlier studies to a considerable extent.” She added: “It affirms that Gulf War veterans, and those with Gulf War Illness, have elevations in many different health problems. These problems are real and often disabling.”

Lessons for the Clinic

Moving forward, “clinicians should be reminded that these veterans have real health problems, are legitimately affected, often in multiple ways, and deserve to be treated with the honor, respect, compassion, and seriousness they deserve," Golomb said.

In an interview with Federal Practitioner, Kimberly Sullivan, PhD, a research associate professor at Boston University School of Public Health who studies GWI, highlighted a new tool within the VA electronic health record that clinicians can use to screen eligible veterans for it. “This is a big improvement from the past when there was no easy way to track veterans with Gulf War Illness in the medical record, even for care providers trying to identify veterans for treatment studies,” said Sullivan, who was not involved in the new study.

Sullivan added that Gulf War veterans should be screened specifically for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome.

The VA’s Health Outcomes Military Exposures program funded the study. The study authors have no disclosures. Haley discloses relationships with the Department of Defense and the VA. Golomb and Sullivan have no disclosures.

Gulf War veterans continue to report significantly higher rates of chronic physical and mental health conditions than their counterparts who did not deploy, according to a new analysis of data from an ongoing cohort study.

Veterans had higher rates in 22 of 47 (47%) self-reported medical conditions compared with nondeployed veterans of the same era, reported US Department of Veterans Affairs (VA) Director of Surveillance Military Environment Exposures for Health Outcomes Military Exposures Erin K. Dursa, PhD, MPH, et al in the Journal of Occupational and Environmental Medicine.

The conditions include chronic fatigue syndrome (13.7% vs 6.2%, respectively; adjusted odds ratio [aOR], 2.44), fibromyalgia (7.5% vs 4.2%, respectively; aOR, 2.05), and irritable bowel syndrome (20.8% vs 13.1%, respectively; aOR, 1.73), all of which are considered key components of Gulf War Illness (GWI), or Gulf War Syndrome. The differences were statistically significant.

“This is still happening. They're still sick with the very same things they’ve had for 34 to 35 years,” Robert Haley, MD, professor of medicine at the University of Texas Southwestern Medical Center in Dallas, told Federal Practitioner in an interview. Haley, who has studied GWI for decades, was familiar with the findings but not involved in the new research.

The US deployed nearly 700,000 troops during the Gulf War. Many troops began reporting chronic illness following deployment, during which some were exposed to oil well fires, nerve agents, pesticides, depleted uranium, and other hazards. An estimated 150,000 troops became sick, Haley said.

“Our group and a couple others started very quickly finding evidence that it was a real illness,” he said. “It was physical, not psychological.”

According to the VA, GWI encompasses chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, and undiagnosed illnesses with symptoms such as abnormal weight loss, fatigue, cardiovascular signs, and muscle and joint pain.

Seeking an Explanation

Research links GWI to exposure to toxic sarin gas, a nerve agent used by Iraq, according to Haley. “It’s analogous to pesticide poisoning,” he said.

Other exposures may play a role, Haley said, but he believes sarin gas is the “major cause.” Sarin gas damages mitochondria within cells, causing them to produce less energy. The actual mechanism, however, remains unknown.

“We're getting real[ly] close to the answer, but we’re not there yet,” Haley said.

A 2000 study reported survey results from 15,000 Gulf War veterans and 15,000 nondeployed counterparts. The deployed veterans had a “higher prevalence of medical conditions, symptoms, functional impairment, and healthcare utilization than Gulf Era veterans.”

The new data, compiled between 2024 and 2025, represent the Gulf War Era cohort study’s fourth follow-up. Researchers surveyed 6888 Gulf War veterans and 5489 nondeployed veterans from the same era (response rate, 46.8%). The Gulf War veterans were 79.9% male; 73.1% White, 20.0% Black, 4.4% Hispanic, and 2.6% identified as another race or ethnicity. Most served in the Army (64.3%), and most were aged 17-25 (37.5%) or 26-32 (29.5%) years at deployment.

The nondeployed veteran group had similar demographics, although the cohort was older. In addition to chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, conditions that were significantly more common in Gulf War veterans than in nondeployed veterans included chronic obstructive pulmonary disease (aOR, 1.62), gastritis (aOR, 1.54), dermatitis (aOR, 1.45), bipolar or manic depression (aOR, 1.45), traumatic brain injury (aOR, 1.43), depression (aOR, 1.38), and alcohol or drug dependence (aOR, 1.36). The differences were statistically significant.

Multiple sclerosis (aOR, 0.42) was significantly less likely to be reported among Gulf War veterans.

The most common conditions reported overall by Gulf War veterans were hypertension (59.9%), sleep apnea (50.8%), arthritis not specified (41.9%), and depression (40.6%).

Affirming Reality

In an interview with Federal Practitioner, Beatrice Golomb, MD, PhD, a professor of medicine at the University of California San Diego and former VA staff physician who studies GWI, noted that researchers adjusted their analyses for body mass index (BMI), although “multiple studies show that weight gain is a metabolic feature of Gulf War Illness.”

This matters, Golomb said, because “if veterans develop increased BMI, and if that increase in BMI then contributes to things like diabetes, heart disease, and other outcomes, then adjusting for BMI will reduce the ability to see the causally-induced problems. For that reason, some problems are likely understated in this article.”

However, Golomb, who was not involved in the study, said the new research “supports findings from earlier studies to a considerable extent.” She added: “It affirms that Gulf War veterans, and those with Gulf War Illness, have elevations in many different health problems. These problems are real and often disabling.”

Lessons for the Clinic

Moving forward, “clinicians should be reminded that these veterans have real health problems, are legitimately affected, often in multiple ways, and deserve to be treated with the honor, respect, compassion, and seriousness they deserve," Golomb said.

In an interview with Federal Practitioner, Kimberly Sullivan, PhD, a research associate professor at Boston University School of Public Health who studies GWI, highlighted a new tool within the VA electronic health record that clinicians can use to screen eligible veterans for it. “This is a big improvement from the past when there was no easy way to track veterans with Gulf War Illness in the medical record, even for care providers trying to identify veterans for treatment studies,” said Sullivan, who was not involved in the new study.

Sullivan added that Gulf War veterans should be screened specifically for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome.

The VA’s Health Outcomes Military Exposures program funded the study. The study authors have no disclosures. Haley discloses relationships with the Department of Defense and the VA. Golomb and Sullivan have no disclosures.

Gulf War veterans continue to report significantly higher rates of chronic physical and mental health conditions than their counterparts who did not deploy, according to a new analysis of data from an ongoing cohort study.

Veterans had higher rates in 22 of 47 (47%) self-reported medical conditions compared with nondeployed veterans of the same era, reported US Department of Veterans Affairs (VA) Director of Surveillance Military Environment Exposures for Health Outcomes Military Exposures Erin K. Dursa, PhD, MPH, et al in the Journal of Occupational and Environmental Medicine.

The conditions include chronic fatigue syndrome (13.7% vs 6.2%, respectively; adjusted odds ratio [aOR], 2.44), fibromyalgia (7.5% vs 4.2%, respectively; aOR, 2.05), and irritable bowel syndrome (20.8% vs 13.1%, respectively; aOR, 1.73), all of which are considered key components of Gulf War Illness (GWI), or Gulf War Syndrome. The differences were statistically significant.

“This is still happening. They're still sick with the very same things they’ve had for 34 to 35 years,” Robert Haley, MD, professor of medicine at the University of Texas Southwestern Medical Center in Dallas, told Federal Practitioner in an interview. Haley, who has studied GWI for decades, was familiar with the findings but not involved in the new research.

The US deployed nearly 700,000 troops during the Gulf War. Many troops began reporting chronic illness following deployment, during which some were exposed to oil well fires, nerve agents, pesticides, depleted uranium, and other hazards. An estimated 150,000 troops became sick, Haley said.

“Our group and a couple others started very quickly finding evidence that it was a real illness,” he said. “It was physical, not psychological.”

According to the VA, GWI encompasses chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, and undiagnosed illnesses with symptoms such as abnormal weight loss, fatigue, cardiovascular signs, and muscle and joint pain.

Seeking an Explanation

Research links GWI to exposure to toxic sarin gas, a nerve agent used by Iraq, according to Haley. “It’s analogous to pesticide poisoning,” he said.

Other exposures may play a role, Haley said, but he believes sarin gas is the “major cause.” Sarin gas damages mitochondria within cells, causing them to produce less energy. The actual mechanism, however, remains unknown.

“We're getting real[ly] close to the answer, but we’re not there yet,” Haley said.

A 2000 study reported survey results from 15,000 Gulf War veterans and 15,000 nondeployed counterparts. The deployed veterans had a “higher prevalence of medical conditions, symptoms, functional impairment, and healthcare utilization than Gulf Era veterans.”

The new data, compiled between 2024 and 2025, represent the Gulf War Era cohort study’s fourth follow-up. Researchers surveyed 6888 Gulf War veterans and 5489 nondeployed veterans from the same era (response rate, 46.8%). The Gulf War veterans were 79.9% male; 73.1% White, 20.0% Black, 4.4% Hispanic, and 2.6% identified as another race or ethnicity. Most served in the Army (64.3%), and most were aged 17-25 (37.5%) or 26-32 (29.5%) years at deployment.

The nondeployed veteran group had similar demographics, although the cohort was older. In addition to chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, conditions that were significantly more common in Gulf War veterans than in nondeployed veterans included chronic obstructive pulmonary disease (aOR, 1.62), gastritis (aOR, 1.54), dermatitis (aOR, 1.45), bipolar or manic depression (aOR, 1.45), traumatic brain injury (aOR, 1.43), depression (aOR, 1.38), and alcohol or drug dependence (aOR, 1.36). The differences were statistically significant.

Multiple sclerosis (aOR, 0.42) was significantly less likely to be reported among Gulf War veterans.

The most common conditions reported overall by Gulf War veterans were hypertension (59.9%), sleep apnea (50.8%), arthritis not specified (41.9%), and depression (40.6%).

Affirming Reality

In an interview with Federal Practitioner, Beatrice Golomb, MD, PhD, a professor of medicine at the University of California San Diego and former VA staff physician who studies GWI, noted that researchers adjusted their analyses for body mass index (BMI), although “multiple studies show that weight gain is a metabolic feature of Gulf War Illness.”

This matters, Golomb said, because “if veterans develop increased BMI, and if that increase in BMI then contributes to things like diabetes, heart disease, and other outcomes, then adjusting for BMI will reduce the ability to see the causally-induced problems. For that reason, some problems are likely understated in this article.”

However, Golomb, who was not involved in the study, said the new research “supports findings from earlier studies to a considerable extent.” She added: “It affirms that Gulf War veterans, and those with Gulf War Illness, have elevations in many different health problems. These problems are real and often disabling.”

Lessons for the Clinic

Moving forward, “clinicians should be reminded that these veterans have real health problems, are legitimately affected, often in multiple ways, and deserve to be treated with the honor, respect, compassion, and seriousness they deserve," Golomb said.

In an interview with Federal Practitioner, Kimberly Sullivan, PhD, a research associate professor at Boston University School of Public Health who studies GWI, highlighted a new tool within the VA electronic health record that clinicians can use to screen eligible veterans for it. “This is a big improvement from the past when there was no easy way to track veterans with Gulf War Illness in the medical record, even for care providers trying to identify veterans for treatment studies,” said Sullivan, who was not involved in the new study.

Sullivan added that Gulf War veterans should be screened specifically for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome.

The VA’s Health Outcomes Military Exposures program funded the study. The study authors have no disclosures. Haley discloses relationships with the Department of Defense and the VA. Golomb and Sullivan have no disclosures.

Unlike Black individuals in the general population who experience disparities in medical care, Black veterans with several types of cancer were just as likely to survive as non-Black veterans, according to a recently published systematic review and meta-analysis. For some cancers, Black veterans reported even better survival outcomes.

The analysis, published by Drew Moghanaki, MD, MPH, Chief of Thoracic Oncology, Department of Radiation Oncology, University of California, Los Angeles, and codirector, Veterans Affairs (VA) Greater Los Angeles Lung Precision Oncology Program, et al, in JAMA Network Open, found that Black veterans had better overall survival (OS) than non-Black veterans (hazard ratio [HR], 0.93) and cancer-specific survival (CSS) (HR, 0.94).

Black veterans had better survival rates for bladder, laryngeal, lung, oropharyngeal, prostate, and plasma cell cancers.

“Once there's equal access to cancer care, we no longer see the purported biological differences that people think are linked to race,” Moghanaki said in an interview with Federal Practitioner.

General Population: Racial Gap

“We've known for decades that there are differences in cancer outcomes for Black people in the US vs non-Black people,” Moghanaki said.

While the gaps in cancer mortality rates between Blacks and Whites have decreased over the last 25 years, colorectal cancer mortality remained 21% higher among Black people than White people in 2024, according to a report from the American Association for Cancer Research.

The association also reported that overall cancer mortality is 13% higher among Black men than White men, despite only 3% higher incidence. Separately, breast cancer mortality in Black women is 35% higher than in White women, even though their incidence is 6% lower.

Research suggests these disparities exist “not so much because of biology, but instead because of the structural and socioeconomic differences that many Black Americans live with in this country,” Moghanaki said.

The VA is different, he said, because “once you’re eligible for VA health care benefits, you’re getting essentially the same health care regardless of skin color.”

For the study, the researchers sought to determine whether the advantages of the VA system were reflected in cancer survival outcomes.

Methodology: Reviewing 34 Years of Data

The authors analyzed 39 studies including 603,256 veterans treated for cancer between 1983 and 2017. Study sizes ranged from 117 to 145,678 subjects. On average, 29.0% (range, 8.9%-55.0%) of participants were Black. Some studies specifically compared Black and White veterans, but the overall meta-analysis compared Black veterans with non-Black veterans.

A total of 29 studies had sufficient data for meta-analyses, including 20 (69%) focused on prostate cancer, 2 (7%) each on non-small cell lung cancer (NSCLC) and pancreatic cancer, and 1 each (3%) on head and neck cancers, esophageal cancer, bladder cancer, breast cancer, and myeloma.

Worse Outcomes for Black Veterans Were Rare

Of the 27 studies that examined OS, most (63%) found similar survival rates between Black and non-Black veterans, with 9 reporting higher survival for Black veterans and only 1 reporting higher survival for non-Black veterans. Among the 17 studies that evaluated CSS, those numbers were 13, 3, and 1, respectively.

Among veterans with prostate cancer, the pooled HRs for Blacks vs non-Blacks were 0.94 for OS and 0.90 for CSS. For NSCLC, they were 0.92 and 0.98, respectively.

The study notes that Black veterans may represent “a positively selected subgroup with respect to health, resilience, or other unmeasured factors, a phenomenon that has been described as a ‘healthy Black veteran effect.”

Other limitations include the high number of prostate cancer studies in the meta-analysis, while several leading causes of cancer death in the US (colorectal, pancreatic, breast), were underrepresented or absent. The analysis also included few women.

The differences in outcomes by race between the VA and general population may be due to the VA’s commitment to providing access to a full range of care and support, Moghanaki said.

“Veterans who are eligible for VA health care benefits also receive housing support, transportation benefits, caregiver support, social services, and mental health services that is often important for anyone with a diagnosis of cancer,” he said, before adding, “The VA’s footprint is large and able to ensure access to care regardless of where veterans live.”

In an interview with Federal Practitioner, Electra D. Paskett, PhD, professor of cancer research and director of the Division of Cancer Prevention and Control at The Ohio State University College of Medicine, who was not involved in the study, said the findings show that “equal access to state-of-the-art care in a timely manner produces good outcomes.”

She offered this message to VA clinicians: “Keep doing what you are doing!”

Moghanaki reported relationships with Bristol Myers Squibb Foundation and Varian Medical Systems, and he was the sole recipient of funding for the study from the Stanley Iezman and Nancy Stark Endowment for Thoracic Radiation Oncology Research at the David Geffen School of Medicine/University of California, Los Angeles. Some other authors reported additional disclosures. Paskett reports no disclosures.

Unlike Black individuals in the general population who experience disparities in medical care, Black veterans with several types of cancer were just as likely to survive as non-Black veterans, according to a recently published systematic review and meta-analysis. For some cancers, Black veterans reported even better survival outcomes.

The analysis, published by Drew Moghanaki, MD, MPH, Chief of Thoracic Oncology, Department of Radiation Oncology, University of California, Los Angeles, and codirector, Veterans Affairs (VA) Greater Los Angeles Lung Precision Oncology Program, et al, in JAMA Network Open, found that Black veterans had better overall survival (OS) than non-Black veterans (hazard ratio [HR], 0.93) and cancer-specific survival (CSS) (HR, 0.94).

Black veterans had better survival rates for bladder, laryngeal, lung, oropharyngeal, prostate, and plasma cell cancers.

“Once there's equal access to cancer care, we no longer see the purported biological differences that people think are linked to race,” Moghanaki said in an interview with Federal Practitioner.

General Population: Racial Gap

“We've known for decades that there are differences in cancer outcomes for Black people in the US vs non-Black people,” Moghanaki said.

While the gaps in cancer mortality rates between Blacks and Whites have decreased over the last 25 years, colorectal cancer mortality remained 21% higher among Black people than White people in 2024, according to a report from the American Association for Cancer Research.

The association also reported that overall cancer mortality is 13% higher among Black men than White men, despite only 3% higher incidence. Separately, breast cancer mortality in Black women is 35% higher than in White women, even though their incidence is 6% lower.

Research suggests these disparities exist “not so much because of biology, but instead because of the structural and socioeconomic differences that many Black Americans live with in this country,” Moghanaki said.

The VA is different, he said, because “once you’re eligible for VA health care benefits, you’re getting essentially the same health care regardless of skin color.”

For the study, the researchers sought to determine whether the advantages of the VA system were reflected in cancer survival outcomes.

Methodology: Reviewing 34 Years of Data

The authors analyzed 39 studies including 603,256 veterans treated for cancer between 1983 and 2017. Study sizes ranged from 117 to 145,678 subjects. On average, 29.0% (range, 8.9%-55.0%) of participants were Black. Some studies specifically compared Black and White veterans, but the overall meta-analysis compared Black veterans with non-Black veterans.

A total of 29 studies had sufficient data for meta-analyses, including 20 (69%) focused on prostate cancer, 2 (7%) each on non-small cell lung cancer (NSCLC) and pancreatic cancer, and 1 each (3%) on head and neck cancers, esophageal cancer, bladder cancer, breast cancer, and myeloma.

Worse Outcomes for Black Veterans Were Rare

Of the 27 studies that examined OS, most (63%) found similar survival rates between Black and non-Black veterans, with 9 reporting higher survival for Black veterans and only 1 reporting higher survival for non-Black veterans. Among the 17 studies that evaluated CSS, those numbers were 13, 3, and 1, respectively.

Among veterans with prostate cancer, the pooled HRs for Blacks vs non-Blacks were 0.94 for OS and 0.90 for CSS. For NSCLC, they were 0.92 and 0.98, respectively.

The study notes that Black veterans may represent “a positively selected subgroup with respect to health, resilience, or other unmeasured factors, a phenomenon that has been described as a ‘healthy Black veteran effect.”

Other limitations include the high number of prostate cancer studies in the meta-analysis, while several leading causes of cancer death in the US (colorectal, pancreatic, breast), were underrepresented or absent. The analysis also included few women.

The differences in outcomes by race between the VA and general population may be due to the VA’s commitment to providing access to a full range of care and support, Moghanaki said.

“Veterans who are eligible for VA health care benefits also receive housing support, transportation benefits, caregiver support, social services, and mental health services that is often important for anyone with a diagnosis of cancer,” he said, before adding, “The VA’s footprint is large and able to ensure access to care regardless of where veterans live.”

In an interview with Federal Practitioner, Electra D. Paskett, PhD, professor of cancer research and director of the Division of Cancer Prevention and Control at The Ohio State University College of Medicine, who was not involved in the study, said the findings show that “equal access to state-of-the-art care in a timely manner produces good outcomes.”

She offered this message to VA clinicians: “Keep doing what you are doing!”

Moghanaki reported relationships with Bristol Myers Squibb Foundation and Varian Medical Systems, and he was the sole recipient of funding for the study from the Stanley Iezman and Nancy Stark Endowment for Thoracic Radiation Oncology Research at the David Geffen School of Medicine/University of California, Los Angeles. Some other authors reported additional disclosures. Paskett reports no disclosures.

Unlike Black individuals in the general population who experience disparities in medical care, Black veterans with several types of cancer were just as likely to survive as non-Black veterans, according to a recently published systematic review and meta-analysis. For some cancers, Black veterans reported even better survival outcomes.

The analysis, published by Drew Moghanaki, MD, MPH, Chief of Thoracic Oncology, Department of Radiation Oncology, University of California, Los Angeles, and codirector, Veterans Affairs (VA) Greater Los Angeles Lung Precision Oncology Program, et al, in JAMA Network Open, found that Black veterans had better overall survival (OS) than non-Black veterans (hazard ratio [HR], 0.93) and cancer-specific survival (CSS) (HR, 0.94).

Black veterans had better survival rates for bladder, laryngeal, lung, oropharyngeal, prostate, and plasma cell cancers.

“Once there's equal access to cancer care, we no longer see the purported biological differences that people think are linked to race,” Moghanaki said in an interview with Federal Practitioner.

General Population: Racial Gap

“We've known for decades that there are differences in cancer outcomes for Black people in the US vs non-Black people,” Moghanaki said.

While the gaps in cancer mortality rates between Blacks and Whites have decreased over the last 25 years, colorectal cancer mortality remained 21% higher among Black people than White people in 2024, according to a report from the American Association for Cancer Research.

The association also reported that overall cancer mortality is 13% higher among Black men than White men, despite only 3% higher incidence. Separately, breast cancer mortality in Black women is 35% higher than in White women, even though their incidence is 6% lower.

Research suggests these disparities exist “not so much because of biology, but instead because of the structural and socioeconomic differences that many Black Americans live with in this country,” Moghanaki said.

The VA is different, he said, because “once you’re eligible for VA health care benefits, you’re getting essentially the same health care regardless of skin color.”

For the study, the researchers sought to determine whether the advantages of the VA system were reflected in cancer survival outcomes.

Methodology: Reviewing 34 Years of Data

The authors analyzed 39 studies including 603,256 veterans treated for cancer between 1983 and 2017. Study sizes ranged from 117 to 145,678 subjects. On average, 29.0% (range, 8.9%-55.0%) of participants were Black. Some studies specifically compared Black and White veterans, but the overall meta-analysis compared Black veterans with non-Black veterans.

A total of 29 studies had sufficient data for meta-analyses, including 20 (69%) focused on prostate cancer, 2 (7%) each on non-small cell lung cancer (NSCLC) and pancreatic cancer, and 1 each (3%) on head and neck cancers, esophageal cancer, bladder cancer, breast cancer, and myeloma.

Worse Outcomes for Black Veterans Were Rare

Of the 27 studies that examined OS, most (63%) found similar survival rates between Black and non-Black veterans, with 9 reporting higher survival for Black veterans and only 1 reporting higher survival for non-Black veterans. Among the 17 studies that evaluated CSS, those numbers were 13, 3, and 1, respectively.

Among veterans with prostate cancer, the pooled HRs for Blacks vs non-Blacks were 0.94 for OS and 0.90 for CSS. For NSCLC, they were 0.92 and 0.98, respectively.

The study notes that Black veterans may represent “a positively selected subgroup with respect to health, resilience, or other unmeasured factors, a phenomenon that has been described as a ‘healthy Black veteran effect.”

Other limitations include the high number of prostate cancer studies in the meta-analysis, while several leading causes of cancer death in the US (colorectal, pancreatic, breast), were underrepresented or absent. The analysis also included few women.

The differences in outcomes by race between the VA and general population may be due to the VA’s commitment to providing access to a full range of care and support, Moghanaki said.

“Veterans who are eligible for VA health care benefits also receive housing support, transportation benefits, caregiver support, social services, and mental health services that is often important for anyone with a diagnosis of cancer,” he said, before adding, “The VA’s footprint is large and able to ensure access to care regardless of where veterans live.”

In an interview with Federal Practitioner, Electra D. Paskett, PhD, professor of cancer research and director of the Division of Cancer Prevention and Control at The Ohio State University College of Medicine, who was not involved in the study, said the findings show that “equal access to state-of-the-art care in a timely manner produces good outcomes.”

She offered this message to VA clinicians: “Keep doing what you are doing!”

Moghanaki reported relationships with Bristol Myers Squibb Foundation and Varian Medical Systems, and he was the sole recipient of funding for the study from the Stanley Iezman and Nancy Stark Endowment for Thoracic Radiation Oncology Research at the David Geffen School of Medicine/University of California, Los Angeles. Some other authors reported additional disclosures. Paskett reports no disclosures.

Interviews with a small sample of veterans seeking disability compensation for military sexual trauma (MST) reveal the US Department of Veterans Affairs (VA) claims process may retraumatize victims by invalidating their experiences and forcing them to relive their assaults, according to a new report.

For some victims, “retraumatization and invalidation contributed to perceptions of VA-enacted institutional betrayal, which impacted their trust in and likelihood of using VA health care,” report Aliya R. Webermann, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in the Journal of Trauma & Dissociation.

One participant recalled that having to write about her trauma “was a big trigger. It was hard. When I was typing it, in the back of my mind, that’s all I could remember. It’s like going through this whole thing all over again.” Another described writing her statement as “brutal.”

Clinical psychologist Anne P. DePrince, PhD, a professor at the University of Denver not involved in the research, said in an interview with Federal Practitioner that the findings “add to a growing number of studies showing that institutional policies can be more than just red tape.

“Policies and procedures, and how those are implemented by staff, can have real consequences for survivors of intimate abuse, adding to the psychological burden they bear.”

The Burden of Military Sexual Trauma

According to a 2016 meta-analysis, 15.7% of US service members and veterans have experienced MST when measured as combined sexual assault and harassment. Viewed separately, assault was reported by 13.9%, including 23.6% of women and 1.9% of men, while harassment was reported by 31.2%, including 52.5% of women and 8.9% of men. The VA defines MST as “sexual assault or threatening sexual harassment experienced during military service.” MST has been linked to posttraumatic stress disorder (PTSD), substance misuse, suicidality, and other adverse outcomes, the new study notes.

Veterans are eligible for service-connected disability compensation for any condition, such as PTSD precipitated by MST, the study authors write, but patients must provide evidence of the trauma and show that the MST caused their disability.

A 2024 analysis found that MST-related PTSD claims for disability were more likely to be denied than combat-related PTSD claims (27.6% vs 18.2%, respectively).

‘I Had to Relive All of That Again’

The researchers recruited 15 victims of MST for interviews in 2024 (73% women, 60% White, 60% Army, mean age 52.6 years). Most served prior to 9/11 and lived in a single state.

In the conversations, which addressed the MST-related claims process, participants described being forced to repeat their stories. “When it was time for me to sit down and write, I had to relive all of that again. It was kind of rough,” one participant said.

Four veterans said being asked to recall their traumas was especially difficult when they were already doing so as part of treatment: “Through therapy, I gotta keep telling the same thing over and over, and it gets old . . . isn’t once enough?” said one veteran, while a male veteran said the experience was “like a knife going into your gut all the time.”

Victims Told They Don’t Fit the Mold

Veterans also described stress during the process.

“It would make me shut down,” said one participant about trying to appeal an initial 10% disability rating. “I used to drink a lot. It took a toll not just on me, but on my relationship.”

Two of the 15 veterans were denied disability, and they described reading their files as traumatic.

“When I read what they put, sometimes I feel as if I’m being assaulted all over again,” one said.

Additionally, some veterans “described being confronted when their lives did not follow a simple pattern of behavior before and after their MST,” the authors write.

One female veteran said: “They were like, ‘But you continued to perform so well and do well in class and still be able to be a military rock star.’ People deal with trauma in different ways. I don’t have to do a 180 and s— the bed to show this is impacting me.”

In other comments, veterans spoke about racial divides—the 2024 analysis found Black veterans were more likely to be denied MST-related disability claims than White veterans—“the living hell” of denied claims, and perceptions of the VA as “an institutional adversary that was distrustful and untrustworthy.”

DePrince said the study highlights the importance of preparing trauma survivors for what they will experience in the claims process.

“My team has learned from survivors across multiple studies just how important clear and accurate information is when trying to navigate legal, health, and social service systems,” she said. “Unfortunately, many survivors find it hard to get clear and accurate information about these processes, which adds to the stress of trying to access much-needed care and resources after trauma.”

Clinical psychologist Sheela Raja, PhD, an associate professor at the University of Illinois Chicago who studies how trauma affects survivors, agreed with DePrince in an interview with Federal Practitioner.

“When survivors know what’s coming, they can prepare, and that alone can make a huge difference,” said Raja, who was familiar with the study findings.

Raja, who has written books about trauma and PTSD, called research such as this “essential.” These reports bring “survivors’ voices forward and help us understand not just their experiences, but the symptoms and stress that can come from navigating systems that weren’t designed with trauma in mind.”

The VA funded the study. The authors have no disclosures. DePrince is associate editor of the Journal of Trauma and Dissociation, where the study appeared, but she was not involved in the review of the paper. Raja has no disclosures.

Interviews with a small sample of veterans seeking disability compensation for military sexual trauma (MST) reveal the US Department of Veterans Affairs (VA) claims process may retraumatize victims by invalidating their experiences and forcing them to relive their assaults, according to a new report.

For some victims, “retraumatization and invalidation contributed to perceptions of VA-enacted institutional betrayal, which impacted their trust in and likelihood of using VA health care,” report Aliya R. Webermann, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in the Journal of Trauma & Dissociation.

One participant recalled that having to write about her trauma “was a big trigger. It was hard. When I was typing it, in the back of my mind, that’s all I could remember. It’s like going through this whole thing all over again.” Another described writing her statement as “brutal.”

Clinical psychologist Anne P. DePrince, PhD, a professor at the University of Denver not involved in the research, said in an interview with Federal Practitioner that the findings “add to a growing number of studies showing that institutional policies can be more than just red tape.

“Policies and procedures, and how those are implemented by staff, can have real consequences for survivors of intimate abuse, adding to the psychological burden they bear.”

The Burden of Military Sexual Trauma

According to a 2016 meta-analysis, 15.7% of US service members and veterans have experienced MST when measured as combined sexual assault and harassment. Viewed separately, assault was reported by 13.9%, including 23.6% of women and 1.9% of men, while harassment was reported by 31.2%, including 52.5% of women and 8.9% of men. The VA defines MST as “sexual assault or threatening sexual harassment experienced during military service.” MST has been linked to posttraumatic stress disorder (PTSD), substance misuse, suicidality, and other adverse outcomes, the new study notes.

Veterans are eligible for service-connected disability compensation for any condition, such as PTSD precipitated by MST, the study authors write, but patients must provide evidence of the trauma and show that the MST caused their disability.

A 2024 analysis found that MST-related PTSD claims for disability were more likely to be denied than combat-related PTSD claims (27.6% vs 18.2%, respectively).

‘I Had to Relive All of That Again’

The researchers recruited 15 victims of MST for interviews in 2024 (73% women, 60% White, 60% Army, mean age 52.6 years). Most served prior to 9/11 and lived in a single state.

In the conversations, which addressed the MST-related claims process, participants described being forced to repeat their stories. “When it was time for me to sit down and write, I had to relive all of that again. It was kind of rough,” one participant said.

Four veterans said being asked to recall their traumas was especially difficult when they were already doing so as part of treatment: “Through therapy, I gotta keep telling the same thing over and over, and it gets old . . . isn’t once enough?” said one veteran, while a male veteran said the experience was “like a knife going into your gut all the time.”

Victims Told They Don’t Fit the Mold

Veterans also described stress during the process.

“It would make me shut down,” said one participant about trying to appeal an initial 10% disability rating. “I used to drink a lot. It took a toll not just on me, but on my relationship.”

Two of the 15 veterans were denied disability, and they described reading their files as traumatic.

“When I read what they put, sometimes I feel as if I’m being assaulted all over again,” one said.

Additionally, some veterans “described being confronted when their lives did not follow a simple pattern of behavior before and after their MST,” the authors write.

One female veteran said: “They were like, ‘But you continued to perform so well and do well in class and still be able to be a military rock star.’ People deal with trauma in different ways. I don’t have to do a 180 and s— the bed to show this is impacting me.”

In other comments, veterans spoke about racial divides—the 2024 analysis found Black veterans were more likely to be denied MST-related disability claims than White veterans—“the living hell” of denied claims, and perceptions of the VA as “an institutional adversary that was distrustful and untrustworthy.”

DePrince said the study highlights the importance of preparing trauma survivors for what they will experience in the claims process.

“My team has learned from survivors across multiple studies just how important clear and accurate information is when trying to navigate legal, health, and social service systems,” she said. “Unfortunately, many survivors find it hard to get clear and accurate information about these processes, which adds to the stress of trying to access much-needed care and resources after trauma.”

Clinical psychologist Sheela Raja, PhD, an associate professor at the University of Illinois Chicago who studies how trauma affects survivors, agreed with DePrince in an interview with Federal Practitioner.

“When survivors know what’s coming, they can prepare, and that alone can make a huge difference,” said Raja, who was familiar with the study findings.

Raja, who has written books about trauma and PTSD, called research such as this “essential.” These reports bring “survivors’ voices forward and help us understand not just their experiences, but the symptoms and stress that can come from navigating systems that weren’t designed with trauma in mind.”

The VA funded the study. The authors have no disclosures. DePrince is associate editor of the Journal of Trauma and Dissociation, where the study appeared, but she was not involved in the review of the paper. Raja has no disclosures.

Interviews with a small sample of veterans seeking disability compensation for military sexual trauma (MST) reveal the US Department of Veterans Affairs (VA) claims process may retraumatize victims by invalidating their experiences and forcing them to relive their assaults, according to a new report.

For some victims, “retraumatization and invalidation contributed to perceptions of VA-enacted institutional betrayal, which impacted their trust in and likelihood of using VA health care,” report Aliya R. Webermann, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in the Journal of Trauma & Dissociation.

One participant recalled that having to write about her trauma “was a big trigger. It was hard. When I was typing it, in the back of my mind, that’s all I could remember. It’s like going through this whole thing all over again.” Another described writing her statement as “brutal.”

Clinical psychologist Anne P. DePrince, PhD, a professor at the University of Denver not involved in the research, said in an interview with Federal Practitioner that the findings “add to a growing number of studies showing that institutional policies can be more than just red tape.

“Policies and procedures, and how those are implemented by staff, can have real consequences for survivors of intimate abuse, adding to the psychological burden they bear.”

The Burden of Military Sexual Trauma

According to a 2016 meta-analysis, 15.7% of US service members and veterans have experienced MST when measured as combined sexual assault and harassment. Viewed separately, assault was reported by 13.9%, including 23.6% of women and 1.9% of men, while harassment was reported by 31.2%, including 52.5% of women and 8.9% of men. The VA defines MST as “sexual assault or threatening sexual harassment experienced during military service.” MST has been linked to posttraumatic stress disorder (PTSD), substance misuse, suicidality, and other adverse outcomes, the new study notes.

Veterans are eligible for service-connected disability compensation for any condition, such as PTSD precipitated by MST, the study authors write, but patients must provide evidence of the trauma and show that the MST caused their disability.

A 2024 analysis found that MST-related PTSD claims for disability were more likely to be denied than combat-related PTSD claims (27.6% vs 18.2%, respectively).

‘I Had to Relive All of That Again’

The researchers recruited 15 victims of MST for interviews in 2024 (73% women, 60% White, 60% Army, mean age 52.6 years). Most served prior to 9/11 and lived in a single state.

In the conversations, which addressed the MST-related claims process, participants described being forced to repeat their stories. “When it was time for me to sit down and write, I had to relive all of that again. It was kind of rough,” one participant said.

Four veterans said being asked to recall their traumas was especially difficult when they were already doing so as part of treatment: “Through therapy, I gotta keep telling the same thing over and over, and it gets old . . . isn’t once enough?” said one veteran, while a male veteran said the experience was “like a knife going into your gut all the time.”

Victims Told They Don’t Fit the Mold

Veterans also described stress during the process.

“It would make me shut down,” said one participant about trying to appeal an initial 10% disability rating. “I used to drink a lot. It took a toll not just on me, but on my relationship.”

Two of the 15 veterans were denied disability, and they described reading their files as traumatic.

“When I read what they put, sometimes I feel as if I’m being assaulted all over again,” one said.

Additionally, some veterans “described being confronted when their lives did not follow a simple pattern of behavior before and after their MST,” the authors write.

One female veteran said: “They were like, ‘But you continued to perform so well and do well in class and still be able to be a military rock star.’ People deal with trauma in different ways. I don’t have to do a 180 and s— the bed to show this is impacting me.”

In other comments, veterans spoke about racial divides—the 2024 analysis found Black veterans were more likely to be denied MST-related disability claims than White veterans—“the living hell” of denied claims, and perceptions of the VA as “an institutional adversary that was distrustful and untrustworthy.”

DePrince said the study highlights the importance of preparing trauma survivors for what they will experience in the claims process.

“My team has learned from survivors across multiple studies just how important clear and accurate information is when trying to navigate legal, health, and social service systems,” she said. “Unfortunately, many survivors find it hard to get clear and accurate information about these processes, which adds to the stress of trying to access much-needed care and resources after trauma.”

Clinical psychologist Sheela Raja, PhD, an associate professor at the University of Illinois Chicago who studies how trauma affects survivors, agreed with DePrince in an interview with Federal Practitioner.

“When survivors know what’s coming, they can prepare, and that alone can make a huge difference,” said Raja, who was familiar with the study findings.

Raja, who has written books about trauma and PTSD, called research such as this “essential.” These reports bring “survivors’ voices forward and help us understand not just their experiences, but the symptoms and stress that can come from navigating systems that weren’t designed with trauma in mind.”

The VA funded the study. The authors have no disclosures. DePrince is associate editor of the Journal of Trauma and Dissociation, where the study appeared, but she was not involved in the review of the paper. Raja has no disclosures.