More Screening Likely to Lead to Increased Breast Cancer Treatment Delays at VA

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By Brenda L. Mooney

BALTIMORE — Women are the fastest growing demographic among U.S. veterans, and the VA sometimes is challenged in keeping up with their needs.

A new study from the Baltimore VA Medical Center looked at what happened when breast cancer screening was increased to accommodate the increasing number of female veterans. The report, published online recently by JAMA Surgery, discusses how times to treatment increased and how non-VA facilities had to be used to meet the need for follow-up.

The VA has reported that, from 2000 to 2009, the number of women veterans using its healthcare services increased 83%, from 159,630 to 292,921.

“Since prioritizing the expansion of women Veterans Healthcare Services in 2008, under new VA directives, the Baltimore VA Medical Center has significantly accelerated screening mammography services,” Ajay Jain MD, chief of surgical oncology at the Baltimore VAMC, told U.S. Medicine. “Our mammography volumes increased by 1,200% in the 2008 to 2012 interval compared to the 2000 to 2007 interval. Our facility also has been treating more female breast cancer patients.”

The time from diagnosis of breast cancer to definitive breast cancer treatment also increased from an average of 33 days to 51 days, and Jain suggested the “reason for this may be multifold. First, the increased time to treatment may simply be related to the fact that our facility is seeing and treating more patients with breast disease and cancer. It may also be related to the fact that the Baltimore VA Medical Center still does not have some resources for advanced breast cancer care on site and utilizes non-VA facilities when these services are needed.”

Mammographic Technician Julie Moseley points out an area of interest on a digital mammography image to Cindy Bone, secretary of Radiology Service at the Durham, NC, VAMC.

He pointed out that, to address the issue, the Baltimore VAMC is actively acquiring more technology and onsite resources necessary for advanced breast cancer treatment, with a new Linear Accelerator Suite for Radiation Oncology opening in the spring. It is expected to improve care for a variety of cancers, including breast.

For the study, all breast cancer cases treated at the facility from January 2001 through May 2012 were examined. In 2008, in response to the growing population of female veterans, the facility expanded screening mammography, developed on-site breast care resources and began to better coordinate care with non-VA facilities.

From 2000 to 2013, 7,355 mammograms were performed and 76 patients with breast cancer received treatment, with most of those, 6,720, after 2008. Annually, there were a median of 1,453 mammograms performed with about six patients receiving cancer care treatment after 2008, according to the study results. That represented 1,200% and 49% increases, respectively, compared with the 2000 to 2007 time period.

Most patients receiving cancer care treatment, 86.7%, had to use multiple institutions to receive screening and diagnostic imaging, biopsy and surgery.

“In summary, we have shown that our hospital successfully expanded mammography,” the authors conclude. “Intensified screening has increased clinical volumes and the need to use non-VA resources, and screening has been associated with an increase in time to definitive treatment. Although this was a single-center, retrospective study, it is probable that our findings are applicable to other VA hospitals.”

Jain said the study points out the need for expansion of breast cancer screening and treatment capabilities within the VA system.

“The take-home message from our study is that, with the expansion of screening mammography, we should expect to treat more breast-cancer patients,” he said. “Using the Baltimore VA Medical Center as a model, the VA therefore should continue to acquire the necessary resources, such as capacity to do advanced diagnostic mammography, breast MRI, ultrasound, stereotactic biopsy, as well as employ clinical staff with expertise in breast cancer.”

Graph comparing occurances of breast cancer screenings of VA vs. Non-VA women
  1. Kvasnovsky CL, Kesmodel SB, Gragasin JL, Punnoose V, Johnson PA, Goel R, Reddy SK, Pierson RN, Jain A. Expansion of Screening Mammography in the Veterans Health Administration: Implications for Breast Cancer Treatment. JAMA Surg. 2013 Sep 18. doi: 10.1001/jamasurg.2013.3738. [Epub ahead of print] PubMed PMID: 24048217.

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