Cancer is more prevalent in the military veteran population than in the general population and is often associated with radiation and chemical exposures encountered while in service. Veterans with cancer may have complex comorbidities, including mental health conditions and social challenges, that can interfere with successful cancer treatment. As more veterans receive their cancer care in the community outside the Veterans Health Administration (VHA), oncology nurses must be aware of these issues and provide appropriate interventions to increase the likelihood that positive cancer treatment outcomes are realized for these patients.
AT A GLANCE
- Veterans with cancer may have more complex comorbidities and other challenges, which may have an adverse effect on effective cancer treatment.
- Because of the VA MISSION Act of 2018, many veterans will receive cancer care in the community setting.
- Oncology nurses in community settings should maintain strong communication with a veteran’s VHA healthcare team to help enhance positive outcomes.
Veterans of the U.S. Armed Forces encompass less than 10% of the adult population in the United States (Bialik, 2017). However, that number is substantial, with 18.6 million military veterans living in the United States in 2017 (National Center for Veterans Analysis and Statistics, 2017). Although the proportion of those individuals who seek health care within the Veterans Health Administration (VHA) is substantively less, it is increasing. More than six million veterans used health care from the VHA in 2019, which is an increase of one million since 2007 (National Center for Veterans Analysis and Statistics, 2020). However, most military veterans receive their health care within the community (i.e., outside the VHA).
Cancer in Veterans
Cancer is more prevalent in veterans than in the general population (Eibner et al., 2016). Veterans may have unique risk factors for developing cancer because of their military deployment. Within the veteran population, the best-known association between chemical exposure and cancer is Agent Orange, which was used as a defoliant during the Vietnam War. Veterans exposed to this herbicide have an abnormally high risk of developing B-cell malignancies (chronic lymphocytic leukemia, lymphoma, myeloma) and other conditions, such as AL amyloidosis and Parkinson disease (U.S. Department of Veterans Affairs [VA], 2019b).
Many veterans who served in Iraq and Afghanistan were exposed to smoke from burning waste in open-air burn pits. A report from the Institute of Medicine (2011) did not find conclusive evidence to establish an association between this chemical exposure and adverse health conditions, but it acknowledged that the latency period for developing associated illnesses, including cancers, may not be realized for decades.
Veterans who were not deployed outside the United States may still be at risk for exposure to hazardous substances, including chemicals, solvents, pesticides, and lead, that increase the risk of cancer. For example, water contamination at U.S. Marine Corps Base Camp Lejeune has been linked to several types of cancer, including leukemia, myelodysplastic syndromes, and liver, bladder, and kidney cancers (U.S. Department of VA, 2017a). In addition, the use of certain fire-retardant chemicals is being phased out because of their association with adverse health conditions, including cancer. An increased incidence in prostate cancer among Air Force pilots also may be linked to radiation exposure, although this association is not yet proven (Copp & Dasgupta, 2019).
Veterans with cancer may have comorbidities that can affect their cancer care. Diabetes, chronic obstructive pulmonary disease, hearing loss, gastroesophageal reflux disease, cardiovascular disease, and sleep disorders occur more frequently in the veteran population than in the general population (Alexander et al., 2016; Eibner et al., 2016; Hinojosa, 2019). Serious mental illnesses (e.g., schizophrenia, bipolar disorder) are also more common in the veteran population (Trivedi at al., 2015) and may complicate cancer care.
Other mental health disorders are also more prevalent, particularly depression, anxiety (Trivedi et al., 2015), and post-traumatic stress disorder (PTSD), which occurs in more than 36% of veterans (Olenick et al., 2015). PTSD results from witnessing or experiencing a traumatic event and may be associated with even mild traumatic brain injury (TBI). Individuals with PTSD may exhibit extreme avoidance behaviors and hypervigilance and may have persistent intrusive thoughts (Shalev et al., 2017). TBI is a condition diagnosed in veterans, typically from an explosive blast. In veterans of the Afghanistan and Iraq conflicts, the prevalence rates of TBI are variable, but rates as high as 41% have been reported (Oster et al., 2017). Long-term effects of TBI vary but can include irritability, forgetfulness, headaches, poor concentration, and anxiety; later effects include subtle but persistent cognitive deficits, particularly in the executive domain (McKee & Robinson, 2014).
Many veterans contend with significant social issues that can potentially have an adverse effect on cancer care and successful treatment. Almost 25% of the 18.6 million U.S. veterans live in rural areas, predominately in the South (46%) and Midwest (26%) (Holder, 2017). The majority of veterans living in rural areas are from the Vietnam era and are aged in their 60s or older (Holder, 2017). Although not unique to veterans, living in rural areas may limit access to local cancer care; transportation options to larger cancer centers may be limited as well. Homecare options also may be limited (Charlton et al., 2015).
About 9% of homeless adults within the United States, or almost 38,000 individuals, are military veterans (Shane, 2018; U.S. Interagency Council on Homelessness, 2018), and 9% of those are women (Schinka & Byrne, 2018). One-third of these individuals are unsheltered (e.g., living in cars or on the streets). California and Florida have the highest proportion of homeless veterans (25% and 7%, respectively). Although the rate of veteran homelessness is decreasing, the number of older adult (aged older than 60 years) homeless veterans has increased (Schinka & Byrne, 2018).
Substance use disorders are also common in the veteran population, and rates continue to rise, particularly among younger veterans (Teeters et al., 2017). Almost 7% of veterans with cancer have a documented substance use disorder (Ho & Rosenheck, 2018). Tobacco and alcohol (often heavy, episodic alcohol consumption) are the most commonly abused substances (Teeters et al., 2017). Although illicit drug use, including marijuana, is equivalent to that in the civilian population, opioid misuse remains problematic with veterans. These disorders are associated with challenges in maintaining employment and with interpersonal relationships, resulting in an increased risk of having limited financial resources and social support.
These negative social factors can profoundly limit veterans’ social support, which is crucial for effective and successful cancer care. Access to timely cancer care and adherence to medical management may also be reduced based on these factors.
Cancer Care Within the VHA
The VHA is the largest integrated healthcare system in the United States, with 170 medical centers and more than 1,000 outpatient clinics (VHA, n.d.). It provides care for more than nine million veterans. Most VA medical centers have the ability to provide comprehensive cancer care. Social work, nutrition, mental health services, and rehabilitation medicine, including physical and occupational therapy services, are often readily available. Each VA medical center has a palliative care consultation team, and all veterans are entitled to receive hospice care (U.S. Department of VA, 2017b). Most of these services are provided at low or no additional cost to veterans.
In 2018, Congress enacted the VA MISSION Act of 2018 (https://bit.ly/2VStuEd). A key purpose of the legislation is to consolidate access to care within the community for veterans. As a result, veterans can receive health care, including cancer care, within the community if a veteran’s local VA facility is unable to provide such care or if a veteran lives a distance from the VA facility, typically when the average drive time exceeds 60 minutes. To qualify for care within the community, veterans must be enrolled in, or be eligible to receive, VA health care. Approval from VA is required prior to obtaining community care (U.S. Department of VA, 2019a). As a result of the VA MISSION Act, more veterans may be treated in non-VA cancer settings. Therefore, oncology nurses need to know and understand the unique needs of this patient population.
Implications for Nursing
Assessment is an integral component of oncology nursing practice. Nurses should obtain a military history from all adult patients; for veterans, that history should include when and where the patient was stationed and possible exposures (e.g., radiation, chemical) encountered during military service. Veterans who have not previously established care from the VHA may find it beneficial to do so during their cancer illness trajectory. For example, veterans with cancers known to be associated with exposures encountered during their military service may qualify for additional benefits, including financial benefits. Other veterans may qualify for their actual cancer treatment, typically at low or no cost (see Figure 1).
Nurses also need to be cognizant of potential mental health and social issues these individuals may have that can negatively affect cancer care. For example, many veterans with mild TBI may have mild cognitive or memory impairment that can affect their ability to adhere to the cancer treatment plan. Veterans with PTSD may exhibit hypervigilance or extreme avoidance behaviors; establishing a trusting relationship may be difficult. Oncology nurses should be aware of their patients’ social challenges, extent of social support, and concurrent health conditions, including mental health, which may affect cancer treatment. Referral to relevant mental health and social work services can be beneficial.
As described previously, veterans enrolled in VHA services tend to have more complex medical conditions, lower mental and physical health functioning, and lower socioeconomic resources, as compared with veterans not engaged in VHA care (Duan-Porter et al., 2018). Therefore, nurses in the community may now encounter veteran patients with more complex health problems as these individuals transition their cancer care from the VHA to the community. These veterans who are referred to the community for cancer care may need additional support services. Connecting with the referring VHA provider to obtain additional social and mental health information can improve nurses’ ability to optimize community cancer care and enhance outcomes.
The majority of U.S. military veterans do not receive their health care from the VHA, including cancer care. Therefore, oncology nurses within the community will care for the majority of veterans with cancer. These veterans may have complex care needs. Oncology nurses should be cognizant of these needs and target appropriate interventions so that optimal cancer care is provided to this patient population.
About the Author(s)
Mary Laudon Thomas, MS, CNS, AOCN®, is a retired hematology clinical nurse specialist, formerly at VA Palo Alto Health Care System in California. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Thomas can be reached at email@example.com, with copy to CJONEditor@ons.org.
Alexander, M., Ray, M.A., Hébert, J.R., Youngstedt, S.D., Zhang, H., Steck, S.E., . . . Burch, J.B. (2016). The National Veteran Sleep Disorder study: Descriptive epidemiology and secular trends. Sleep, 39(7), 1399–1410. https://doi.org/10.5665/sleep.5972
Bialik, K. (2017). The changing face of America’s veteran population. Pew Research Fact Tank. https://www.pewresearch.org/fact-tank/2017/11/10/the-changing-face-of-am...
Charlton, M., Schlichting, J., Chioreso, C., Ward, M., & Vikas, P. (2015). Challenges of rural cancer care in the United States. Oncology, 29(9), 633–640
Copp, T., & Dasgupta, S. (2019, July 30). Air Force examining possible increased prostate cancer risk for pilots. https://www.military.com/daily-news/2019/07/30/air-force-examining-possi...
Duan-Porter, W., Martinson, B.C., Greer, N., Taylor, B.C., Ullman, K., McKenzie, L., . . . Wilt, T.J. (2018). Evidence review-social determinants of health for veterans. Journal of General Internal Medicine, 33(10), 1785–1795. https://doi.org/10.1007/s11606-018-4566-8
Eibner, C., Krull, H., Brown, K., Cefalu, M., Mulcahy, A.W., Pollard, M., . . . Farmer, C.M. (2016). Current and projected characteristics and unique health care needs of the patient population served by the Department of Veterans Affairs. RAND Health Quarterly, 5(4), 13.
Hinojosa, R. (2019). Veterans’ likelihood of reporting cardiovascular disease. Journal of the American Board of Family Medicine, 32(1), 50–57. https://doi.org/10.3122/jabfm.2019.01.180148
Ho, P., & Rosenheck, R. (2018). Substance use disorder among current cancer patients: Rates and correlates nationally in the Department of Veterans Affairs. Psychosomatics, 59(3), 267–276. https://doi.org/10.1016/j.psym.2018.01.003
Holder, K.A. (2017). Veterans in rural America: 2011–2015. https://www.census.gov/content/dam/Census/library/publications/2017/acs/...
Institute of Medicine. (2011). Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. National Academies Press. https://doi.org/10.17226/13209
McKee, A.C., & Robinson, M.E. (2014). Military-related traumatic brain injury and neurodegeneration. Alzheimer’s and Dementia, 10(3, Suppl.), S242–S253. https://doi.org/10.1016/j.jalz.2014.04.003
National Center for Veterans Analysis and Statistics. (2017). Profile of veterans: 2017 highlights. https://www.va.gov/vetdata/docs/QuickFacts/2017_Veterans_Profile_Fact_Sh...
National Center for Veterans Analysis and Statistics. (2020). Geographic distribution of VA expenditures. https://va.gov/vetdata/Report.asp
Olenick, M., Flowers, M., & Diaz, V. (2015). US veterans and their unique issues: Enhancing health care professional awareness. Advances in Medical Education and Practice, 6, 635–639. https://doi.org/10.2147/AMEP.S89479
Oster, C., Morello, A., Venning, A., Redpath, P., & Lawn, S. (2017). The health and wellbeing needs of veterans: A rapid review. BMC Psychiatry, 17, 414.
Schinka, J.A., & Byrne, T.H. (2018). Aging and life expectancy in homeless veterans: Nine questions. https://www.va.gov/HOMELESS/nchav/docs/Schinka_Byrne_AgingLifeExpectancy...
Shalev, A., Liberzon, I., & Marmar, C. (2017). Post-traumatic stress disorder. New England Journal of Medicine, 376(25), 2459–2469. https://doi.org/10.1056/NEJMra612499
Shane, L., III. (2018, November 1). Fewer veterans were homeless in 2018, after a worrisome rise last year. Military Times. https://www.militarytimes.com/news/2018/11/01/after-a-worrisome-rise-las...
Teeters, J., Lancaster, C., Brown, D., & Back, S. (2017). Substance use disorders in military veterans: Prevalence and treatment challenges. Substance Abuse and Rehabilitation, 8, 69–77. https://doi.org/10.2147/SAR.S116720
Trivedi, R.B., Post, E.P., Sun, H., Pomerantz, A., Saxon, A.J., Peitte, J.D., . . . Nelson, K. (2015). Prevalence, comorbidity, and prognosis of mental health among US veterans. American Journal of Public Health, 105(12), 2564–2569.
U.S. Department of Veterans Affairs. (2017a). Diseases associated with exposure to contaminants in the water supply at Camp Lejeune. Federal Register, 82(9), 4173–4185. https://www.federalregister.gov/documents/2017/01/13/2017-00499/diseases...
U.S. Department of Veterans Affairs. (2017b). VHA directive 1139: Palliative care consult teams (PCCT) and VISN leads. http://www.va.gov/vhapublications/viewPublication.asp?pub_ID=5424
U.S. Department of Veterans Affairs. (2019a). Community care. https://bit.ly/3cdFtSz
U.S. Department of Veterans Affairs. (2019b). Diseases related to Agent Orange. https://www.va.gov/disability/eligibility/hazardous-materials-exposure/a...
U.S. Department of Veterans Affairs. (2020). Eligibility for VA health care. https://www.va.gov/health-care/eligibility
U.S. Interagency Council on Homelessness. (2018). Homelessness in America: Focus on veterans. https://www.usich.gov/resources/uploads/asset_library/Homelessness_in_Am...
VA.org. (2020). Establishing the service connection. https://va.org/establishing-the-service-connection
Veterans Health Administration. (n.d.). Providing health care for veterans. https://www.va.gov/health