VCS fighting to protect Defense medical research

(Washington — February 28, 2018) — Veterans for Common Sense this week was among 111 organizations to send a letter to Congressional leadership of the Armed Services committees expressing concern about possible renewed efforts to that would have a detrimental impact on research at the Congressionally-Directed Medical Research Program (CDMRP) and other medical research conducted by the U.S. Department of Defense (DoD).

According to the letter:

“Last year, the fiscal year 2018 NDAA reported by the Senate Committee on Armed Services and ultimately approved by the Senate included provisions that would have individually and collectively restricted, if not outright prohibited, medical research on diseases and disorders that affect our nation’s men and women who serve or have served in the U.S. Armed Services.  These provisions (sections 733, 891, 892, and 893 of the Senate bill) would have restricted the types of research that could be funded, and added burdensome contracting and auditing requirements designed for large weapons system contracts.  Moreover, one of these provisions (Section 733) would have affected all medical research at DoD, not just the CDMRP.”

Those provisions were ultimately rejected by Congress, but only after a sustained, all-out battle led by the Defense Health Research Consortium (DHRC), which advocates for medical research within the DoD, especially the CDMRP.  Veterans for Common Sense (VCS) is a charter and executive committee member of the DHRC.  This week’s letter was also led by the DHRC.

VCS  has led extensive, annual national advocacy efforts that result in Congress funding the unique, treatment-focused Gulf War Illness Research Program (GWIRP) — and more recently the Burn Pits Exposure topic area — within the DoD CDMRP.

The full text of the letter is as follows:

February 27, 2018

The Honorable John McCain                                The Honorable Mac Thornberry
Chairman                                                                  Chairman
Senate Committee on Armed Services                House Committee on Armed Services
Russell Senate Building, Room 228                     2216 Rayburn House Office Building
Washington, DC 20510                                          Washington, DC 20515

The Honorable Jack Reed                                     The Honorable Adam Smith
Ranking Member                                                     Ranking Member
Senate Committee on Armed Services                House Committee on Armed Services
Russell Senate Building, Room 228                     2216 Rayburn House Office Building
Washington, DC 20510                                          Washington, DC 20515

Dear Chairmen McCain and Thornberry and Ranking Members Reed and Smith:

As you work to develop your respective versions of the fiscal year 2019 National Defense Authorization Act (NDAA), we encourage you to refrain from including any language that would have a detrimental impact on research at the Congressionally-Directed Medical Research Program (CDMRP) and other medical research conducted by the U.S. Department of Defense (DoD).

Last year, the fiscal year 2018 NDAA reported by the Senate Committee on Armed Services and ultimately approved by the Senate included provisions that would have individually and collectively restricted, if not outright prohibited, medical research on diseases and disorders that affect our nation’s men and women who serve or have served in the U.S. Armed Services.  These provisions (sections 733, 891, 892, and 893 of the Senate bill) would have restricted the types of research that could be funded, and added burdensome contracting and auditing requirements designed for large weapons system contracts.  Moreover, one of these provisions (Section 733) would have affected all medical research at DoD, not just the CDMRP.

In response to the inclusion of this language last year, the U.S. Army’s Medical Research and Materiel Command issued a memorandum that stated:

“This language will impact force readiness and medical providers’ readiness….  Impacts on military medical training programs will negatively affect the readiness of our military health care providers.”

Because the Senate version of the bill is not marked-up in public, our organizations did not have a chance to respond to this language until after the bill was reported from committee.  Furthermore, an amendment to remove this language was filed in the Senate and cosponsored by more than half of the Senate, but was not given a vote on the Senate floor.   After passage of the bill, “Dear Colleague” letters asking for removal of this language in the House-Senate conference were circulated and signed by 54 Senators and 180 Representatives.

Thankfully, the final version of the FY18 NDAA did not include this language.  This result was due in large part to an arduous four-month advocacy campaign by your constituents, who expended an enormous amount of time and energy to defeat language that a clear Majority in Congress opposed from the outset.

The strong level of bipartisan Congressional support for the defense health research programs is a beacon of hope to the military families, retirees, veterans and civilians who must cope with these diseases and disorders.  We urge you to honor their concerns and refrain from including in this year’s NDAA any language that would restrict medical research at DoD.

We appreciate your prompt and urgent consideration of our request.

Sincerely,

AcademyHealth
Action to Cure Kidney Cancer
Adult Congenital Heart Association
ALS Association
American Academy of Dermatology Association
American Academy of Ophthalmology
American Association of Clinical Urologists
American Brain Tumor Association
American College of Rheumatology
American Gastroenterological Association
American Liver Foundation
American Psychological Association
American Urological Association
Aplastic Anemia and MDS International Foundation
Arthritis Foundation
Association of American Cancer Institutes
Association of Public and Land-grant Universities
The Asthma and Allergy Foundation of America
Autism Speaks
Beyond Celiac
Bladder Cancer Advocacy Network
Children’s National Health System
Children’s Tumor Foundation
Christopher & Dana Reeve Foundation
Citizens United for Research in Epilepsy
Coalition for National Security Research (CNSR)
Critical Mass: The Young Adult Cancer Alliance
Crohn’s & Colitis Foundation
CureHHT
Debbie’s Dream Foundation: Curing Stomach Cancer
debra of America
Digestive Disease National Coalition
Duke University
Duke University School of Medicine
Dystonia Advocacy Network
Dystonia Medical Research Foundation
Epilepsy Foundation
Fight Colorectal Cancer
FORCE: Facing Our Risk of Cancer Empowered
Foundation to Eradicate Duchenne
GBS|CIDP Foundation International
Global Health Technologies Coalition
Indiana University
International Foundation for Functional Gastrointestinal Disorders
Interstitial Cystitis Association
Hepatitis B Foundation
Hydrocephalus Association
Indiana University
Infectious Diseases Society of America
International Myeloma Foundation
Kidney Cancer Action Network
Kidney Cancer Association
Leukemia & Lymphoma Society
Littlest Tumor Foundation
Living Beyond Breast Cancer
Lung Cancer Alliance
LUNGevity Foundation
Lupus Foundation of America
Letter to Chairs/Ranking Members
Lymphoma Research Foundation
Malaria No More
Malecare Cancer Support
Marfan Foundation
METAvivor
The Michael J. Fox Foundation for Parkinson’s Research
Muscular Dystrophy Association
National Alliance for Eye and Vision Research
National Alliance of State Prostate Cancer Coalitions
National Autism Association
National Brain Tumor Society
National Fragile X Foundation
National Kidney Foundation
National Multiple Sclerosis Society
National Organization for Rare Disorders (NORD)
NephCure Kidney International
Neurofibromatosis Midwest
Neurofibromatosis Network
Oncology Nursing Society
Ovarian Cancer Research Fund Alliance
Pancreatic Cancer Action Network
Parent Project Muscular Dystrophy
Penn State University
Prostate Cancer Foundation
Pulmonary Hypertension Association
Research!America
Restless Legs Syndrome Foundation
Scleroderma Foundation
The Sergeant Sullivan Circle
Sleep Research Society
Society of Gynecologic Oncology
Stony Brook University
Susan G. Komen
TB Alliance
Texas NF Foundation
Theresa’s Research Foundation
Tuberous Sclerosis Alliance
University of California System
University of Hawaii
University of Iowa
University of New Mexico Health Sciences Center
University of Pittsburgh
University of Virginia School of Medicine
US Hereditary Angioedema Foundation
Us TOO International Prostate Cancer Education & Support
Vanderbilt University
Vanderbilt University Medical Center
Veterans for Common Sense
The Veterans Health Council
Vietnam Veterans of America
Wayne State University
Weill Cornell Medicine
ZERO-The End of Prostate Cancer

cc:  Members of the House and Senate

Enclosure:  Military Relevance of Defense Health Research Programs

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Defense Health Research Programs
Relevance to National Security and Military Families
February 27, 2018

• ALS: According to studies by the Department of Defense (DoD), Department of Veterans Affairs (VA), National Institutes of Health (NIH) and Harvard University, people who have served in the military are approximately twice as likely to develop ALS as the general population[1]. Most recently, researchers found an increased risk of ALS among those who served in Iraq and Afghanistan[2]. The VA has recognized the connection between ALS and military service by establishing a presumption of service connection for ALS[3]. The VA presumes that ALS was incurred in or aggravated by service in the military. Moreover, the presumption applies to any veteran who served, from any branch of the military, regardless of where or when a veteran served (home or abroad, during a time of peace or conflict) and regardless of when they were diagnosed with the disease following discharge (eg, 1 year after service or 50 years). The DoD ALS Research Program is supporting translational research and has developed four potential treatments for the disease, for which there is no cure.
• Autism: According to the Centers for Disease Control and Prevention, 1 in 68 children have an autism spectrum disorder (ASD)[4].  The Department of Defense reports that 18,452 active duty family members had a diagnosis of ASD at the end of fiscal year 2013.[5]  This reflects a 77{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} increase in ASD diagnoses in just four years from fiscal year 2009.[6]   Military families are affected substantially by the financial and emotional costs of raising a child with autism and this impact extends to the performance and readiness of service members and their units.  It is well known that children with autism, if they receive prompt treatment and early intervention services, can improve their long-term functional prospects dramatically.[7]  Research supported by the Autism Research Program has addressed current needs such as difficulties accessing care associated with mobile military families[8] and gastrointestinal (GI) disorders which are among the most common medical conditions associated with autism.[9]  Additional research will help to improve treatment and intervention directly serving the interests of service members and DoD families impacted by autism as well as the medical, educational, healthcare and service professionals who serve the needs of the autism community within and beyond.
• Bladder Cancer: Bladder cancer is the 6th most common cause of cancer in the United States, and the 4th most common cancer within the U.S. veteran population.[10] [11] Smoking is a leading risk factor associated with bladder cancer, but male sex, advancing age, and white race are also strong risk factors.  Despite mounting evidence in the 1950s of the adverse health effects of smoking and tobacco use, the military continued to include cigarettes in rations until 1975.[12] Smoking prevalence in the veteran population is reported to be 27{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} compared to 21{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} in the non-veteran population.[13]  It has also been estimated that the prevalence of smoking is 43{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} higher in the population treated by VA hospitals compared to age matched controls [14]From 1961 to 1971, approximately 1,000,000 gallons of Agent Blue, containing high levels of arsenic were sprayed over the southern region of Vietnam.[15] Inorganic arsenic compounds have been linked to cancer of the bladder.[16] In addition, from the 1950s through the 1980s, people serving or living at the U.S. Marine Corps Base Camp Lejeune, North Carolina, were potentially exposed to drinking water contaminated with industrial solvents, benzene, and other chemicals. This chemical exposure may have led to adverse health conditions, including bladder cancer.[17]
• Bone Marrow Failure Disorder: Myelodysplastic Syndrome (MDS) is rare bone marrow failure disorder that increase risk of developing AML, a fast growing cancer of the blood. Exposure to benzene, historically used extensively by the military, has been well established as a risk factor for myeloid malignancy, and is significantly associated with development of MDS and AML.[18][19][20]  Both ground troops and onboard support personnel have been at risk for significant exposure to dioxin, benzene and Agent Orange herbicide during the Vietnam war. [21][22][23] More recently, veterans stationed at Camp Lejeune between 1953 and 1987 were found to have potential exposure to industrial solvents in well water, inclusive of benzene, as recognized by the VA.[24]   The Bone Marrow Failure Research Program supports critical research into disease etiology and therapy development pathways. Continued research into bone marrow failure etiology and molecular genomics is essential to saving lives.
• Breast Cancer: According to recent demographic reports, active duty females and female spouses under the care of the United States military health system total approximately 1.4 million women.[25] Assuming normal risk of developing breast cancer across a woman’s lifetime (1 in 8), 175,000 cases of breast cancer are expected to be diagnosed within that population.  Furthermore, a 2009 study suggested that active duty females have a higher incidence of breast cancer than the general population, which would increase the expected number of breast cancer cases.[26]  Therefore, breast cancer is a significant issue for the United States military health system. Additionally, military families are affected substantially by the financial and emotional costs of breast cancer and this impact extends to the performance and readiness of service members and their units. The Breast Cancer Research Program has invested in research to better understand how and why breast cancer is initiated, factors that increase risk, and more advanced ways to detect and treat this disease including innovative treatments for breast cancer that are both more effective and less toxic (e.g. sentinel lymph node biopsy, trastuzumab for HER2+ breast cancer, vaccines and immunotherapies for breast cancer, nanoparticle-based drug delivery systems).[27]
• Cancer in Adolescents and Young Adults: Approximately 70,000 adolescents and young adults between the ages of 15 and 39 are diagnosed with cancer each year in the United States. In fact, cancer is the leading cause of disease-related death for this age group.  The National Cancer Institute has found that “evidence suggests that some cancers in adolescents and young adults may have unique genetic and biological features. Researchers are working to learn more about the biology of cancers in young adults so that they can identity molecularly targeted therapies that may be effective in these cancers.”[28]  Unfortunately this age population is not recognized as a unique oncology care group. Adolescents and young adults have no medical “home.” Providers must make care and treatment decisions using research and facilities designed for pediatric or older adult patients. This has led to a lack of improvement in survival rates since the War on Cancer began more than 40 years ago.[29]  Nearly 90{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of servicemembers, their spouse, and children fall within the NCI definition of an adolescent or young adults impacted by cancer.[30]
• Colorectal Cancer: According to a study published in the June 2009 issue of Cancer Epidemiology, Biomarkers & Prevention, researchers found that colorectal cancer was one of the most common forms of cancer among active duty military personnel. Yet, screening rates among military personnel for colorectal cancer remain low. As published in the 2009 Humana Military’s Clinical Quality Report Card, only 58 percent of those in the military were up to date with screening in 2008. The Peer Reviewed Cancer Research Program (PRCRP) has supported research into treatments for colorectal cancer, including research into treatments that would block the growth of metastatic colorectal cancer.

CA093415[31], CA111002[32], CA100879[33], CA100512P1[34], CA093176[35])

• Crohn’s Disease and Ulcerative Colitis (Inflammatory Bowel Diseases): The prevalence of Crohn’s Disease and Ulcerative Colitis (collectively known as inflammatory bowel diseases-IBD) increased by two to threefold among veterans from 1998 to 2009. Researchers found nearly 17,000 unique incident cases of Crohn’s Disease and over 26,000 cases of Ulcerative Colitis within the military population during this time. Due to the population studied, 94{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of the cases were in men. In 2009, the age and gender standardized prevalence rate of Crohn’s Disease was 287 per 100,000 VA users and the prevalence rate for Ulcerative Colitis was 413 per 100,000 VA users.[36] Despite having a large population study, much is yet to be known about etiology or cause of these diseases, therefore continued research in this area is necessary to advance knowledge about IBD.
• Epilepsy: According to 2015 estimates, a staggering 3.4 million Americans suffer from epilepsy.[37]  Individuals who serve in the military are especially susceptible to developing a type of epilepsy called post-traumatic epilepsy (PTE), defined as a recurrent seizure disorder following traumatic brain injury (TBI). [38] TBIs can take the form of bumps, blows to the head, blasts or penetrating injuries,[39] such as those seen so often in the line of duty. In fact, 4.2{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of all troops (Army, Air Force, Navy and Marine Corps combined) who served from 2000 to 2011 were diagnosed with a TBI.[40]  These injuries can have a devastating impact on troops; for example, a reported 53{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of Vietnam veterans who suffered from severe TBI that required neurosurgery subsequently developed epilepsy,[41] and within a group of veterans of Afghanistan and Iraq, those with TBI had 18.77{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} greater odds of developing epilepsy than those without TBI.[42]  The development of epilepsy can also reduce the pool of potential military enlistees: DOD regulations prohibit anyone currently suffering from seizures from admission into the armed services.[43]  Currently, there is no known prevention for PTE following TBI and treatments for PTE are only partially effective and can have severe drawbacks.[44]  There is also no known treatment or cure for many other types of epilepsy that afflict our troops and the general population.[45] Therefore, the continuation of epilepsy research is critical to the health of our troops, our national security and to the well-being of the population as a whole.
• Gulf War Illness: According to a 2014 update report of the Congressionally-mandated Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC), “Scientific research [since 2008] . . . supports and further substantiates . . . that Gulf War illness is a serious physical disease, affecting at least 175,000 veterans of the 1990-1991 Gulf War, that resulted from hazardous exposures in the Gulf War theater.”[46] Studies reviewed in the report found an elevated incidence of Lou Gehrig’s disease (ALS)[47] among Gulf War veterans as well as significantly elevated rates of death due to brain cancer[48] among those who were most exposed to the release of nerve gas by the destruction of the Khamisiyah Iraqi arms depot. In addition to improving the health of Gulf War veterans, important discoveries made by the GWIRP will also help protect current and future American servicemembers who are at risk of similar toxic exposures.[49]
• Hydrocephalus: Hydrocephalus is a chronic neurological condition that affects over one million people in the US. Hydrocephalus has no cure and the only treatment option is brain surgery. Often thought of as a pediatric condition, children can be born with hydrocephalus or develop it after birth, with the premature baby population being at particular risk of post-hemorrhagic hydrocephalus as a result of a brain bleed. Hydrocephalus is the leading cause of brain surgery in children. However, anyone at any time can develop hydrocephalus as it can be caused by a traumatic brain injury, tumor, infection, or as part of the aging process for reasons which are still not understood. This makes hydrocephalus’ impact and reach within our military population deep and wide. Families can be affected if their children are born with or develop the condition. Active service members and veterans who have experienced traumatic brain injury are particularly vulnerable to developing hydrocephalus. Since 2000, more than 333,000 U.S. service members have sustained a traumatic brain injury.[50]  Over 35,000 are at risk of developing hydrocephalus due to the severity of the injury.[51] [52] [53] [54]The Department of Defense does not currently track the development of hydrocephalus, so, while Normal Pressure Hydrocephalus (NPH) affects elderly adults, it is not known if previous injury, even mild injury, increases the risk of NPH.  It is estimated that NPH affects over 700,000 seniors in the United States, including over 180,000 veterans.[55] [56]
• Kidney Cancer: Kidney cancer affects military personnel and their dependents and veterans. The body insult that causes kidney cancer may occur during active service but may not appear until later in life therefore affecting veterans more frequently than their US civilian counterparts. In a 2012 study identifying cancer incidence among patients of the United States Veterans Affairs Healthcare System kidney cancer was the 6th leading cancer.[57] Vietnam veterans exposed to Agent Orange have had kidney cancer. Exposure to ionizing radiation, chemicals and hazardous materials can cause kidney cancer. Smoking, hypertension and obesity are high kidney cancer risk factors. A cohort of about 210,000 U.S. veterans followed for 26 years was analyzed for a study examining the role of smoking in the development of renal cancer.[58]  The follow-up of these military veterans revealed 719 deaths from renal cancer, making this one of the largest studies of renal cancer and cigarette smoking. Current smokers had a 47 percent increase in risk for renal cancer relative to nonsmokers, and the relative risk correlated positively with the number of cigarettes smoked per day. These results were later confirmed by several independent studies showing that about one fifth to one third of renal cancer is associated with smoking. Cigarette smoking generates oxidative stress, which is implicated as one of the direct chemical factors in renal oncogenesis. Most recently, researchers from Oak Ridge National Laboratory demonstrated a near real-time generation of hydrogen peroxide by cigarette smoke. According to a 2014 report issued by the Centers for Disease Control and Prevention US Marines and their families stationed at Camp Lejeune, North Carolina have a 35{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} higher risk of contracting kidney cancer than their US counterparts due to contaminated drinking water.[59]
• Leukemia/Lymphoma/Multiple Myeloma: Many of the blood cancers are linked to chemical and radiologic exposure during deployment.  Leukemia, non-Hodgkin Lymphoma (NHL), Hodgkin Lymphoma (HL), and multiple myeloma have all been connected to chemical weapons, or storage, ionizing radiation, herbicides, electromagnetic fields, jet fuel, organic materials, etc.  The Selected Cancers Cooperative Study Group showed that veterans of the Vietnam War had a 50{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} increase of risk of HL as compared to subjects who had not served in Vietnam.  Evidence associates an increased risk for NHL, HL, and chronic lymphocytic leukemia to Vietnam War service and exposure to herbicides such as Agent Orange.[60]
• Lung Cancer: Numerous studies over the years published by the Institute of Medicine, Cancer, Military Medicine, Chest and others have shown that lung cancer incidence and mortality rates, due to much higher smoking rates and exposures to known carcinogens during active duty, are an estimated 25{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} – 30{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} higher in the military than in civilian populations.  [61] [62] [63] [64] Of growing concern is the lung cancer risk among ground troops deployed during the Gulf Wars whose exposures included asbestos, chromium, diesel exhaust, radon, crystalline silica, pesticides, pollutants and particulate matter from burn pits, oil well fires and the destruction of chemical weapons including sarin gas. Research focused on these veterans is urgently needed. Given lung cancer’s long latency period, and the fact that the average age of Gulf War veterans is now in the mid-fifties, research projects should incorporate CT screening as a platform.
• Lupus: Lupus is a debilitating autoimmune disease up to three times more common among African Americans, Hispanics and Native Americans and it affects over one-and-a-half million persons in the U.S. –90 percent of whom are women. The disease often strikes young women of childbearing age who experience symptoms such as intense fatigue and exhaustion, joint pains, cognitive and memory problems, and skin rashes. It can also manifest in kidney problems, premature heart disease, strokes or lung inflammation.  Defense Department data show that women now make up a much greater share of our armed forces than they have at any time in U.S. history. Women account for almost 15 percent of active duty Service Members, almost 20 percent of Reserves and 15.5 percent of the National Guard.[65] A recent Pew Research Center report found that the active-duty female force is racially diverse –nearly one-third (31{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d}) of active-duty women are black (including black Hispanics).[66]  Twelve percent of women in the Armed Forces report their ethnicity as Hispanic, whether white or black. Our nation now has over 2 million women veterans, about 9 percent of the total veteran population, a figure expected to rise to 15 percent by 2035.[67] [68]
• Melanoma: A 2000 “Annals of Epidemiology” study comparing mortality among WWII veterans of the Pacific and European Theaters found that Pacific Theater Prisoner of War veterans had an estimated 3-fold higher risk of dying from melanoma than veterans of the European Theater, concluding that exposure to high levels of solar radiation in young adulthood is associated with a higher risk of melanoma mortality.[69]  Given this information, U.S. military personnel currently stationed in Iraq and Afghanistan, where the intensity of sun exposure is similar to that of the Pacific, have the potential for a long-term risk of melanoma. According to the American Cancer Society, the American Academy of Dermatology and the Melanoma Research Foundation, skin cancer is the most commonly diagnosed cancer in the United States. Melanoma, the deadliest type of skin cancer, kills an estimated 10,000 Americans each year. Furthermore, people of all ages, races and genders are at risk. Melanoma is the most common form of cancer for young adults 25-29, the second most common form of cancer for young people 15-29 and SEER data suggests that the majority of people diagnosed with melanoma are white men over the age of 50.[70] [71] [72]
• Multiple Sclerosis: There are currently over 32,000 veterans with diagnosed multiple sclerosis (MS).and over 11,000 of those veterans have a service connected disability for MS.[73] MS is an unpredictable, often disabling disease of the central nervous system that interrupts the flow of information within the brain, and between the brain and the body. Symptoms range from numbness and tingling to blindness and paralysis. The progress, severity and specific symptoms of MS in any one person cannot yet be predicted. Each year the Veterans Health Administration provides care to more than 28,000 veterans living with MS each year.[74] Currently, there is a presumptive period for a service connected benefit for MS. Individuals who are diagnosed with MS while they are in the military or within seven years of their honorable discharge are eligible for a service-connected disability. A 2003 review found that 5,345 veterans that served in Vietnam and the first Gulf War were diagnosed with MS that was deemed “service-connected.”[75] The relative risk for developing MS also was significantly higher for this group of veterans than those who served in World War II and the Korean War.[76]   An advisory committee commissioned by the VA has recommended further study into the potential link between combat service and the increased risk of developing MS.[77]  By studying this population, scientists might be able to understand the cause and triggers of MS and develop effective treatments.
• Neurofibromatosis (NF): NF research critically addresses areas of great clinical need directly affecting the health of our soldiers. The genetic information learned from NF research holds the key to understanding a number of health issues that affect the war fighter, as well as the general population, including cancer, bone fracture and repair, vascular disease, wound healing and nerve regeneration, deafness, behavioral and psychosocial issues, learning disabilities, muscle weakness, and pain. For example, NF often requires surgical removal of nerve tumors, which can lead to nerve paralysis and loss of function, similar to nerve damage sustained by the war fighter after injury. Understanding how nerves and skin might be regenerated and functionally restored will have significant quality of life value for affected individuals. Current NF research aims to develop a rapid approach for taking a person’s skin stem cells and differentiating them into cell types that need replacing after injury. This work will advance skin regeneration research and elucidate the potential of skin derived stem cells to make other cell types such as nerve cells, to restore function after injury. In another example, orthopedists, NF-ologists and tissue engineers are collaborating to investigate innovative technologies that will improve the healing of challenging and recurring bone breaks in NF patients, research that directly benefits war fighters with major bone breakages. Therefore, due to the nature of the wounds and recovery that soldiers are enduring, NF research is of particular benefit to the military mission. Proposals include: NF080017[78], NF120087[79], NF110052[80] and NF110052[81]
• Osteoarthritis (OA): Current research suggests that stresses placed on joints during military training activities, increased rates of injury, and increased weight of military packs have led active duty soldiers and veterans to have twice the rate of Osteoarthritis (OA) when compared to non-military populations. In fact, OA is the leading cause of disability and medical discharge in active service members under the age of 40.  Rheumatoid arthritis (RA) strikes at the peak one’s career (mid-late thirties/forties) and often leads to early retirement and disability. CDMRP research funding for OA and RA could help identify arthritis prior to the onset of symptoms. This research could help identify medical and physical interventions to prevent or minimize joint damage and slow or stop the arthritis disease process before joints are permanently damaged. Targeted research efforts would focus on examining genetic factors, ways to improve diagnosis, screening, and treatment options. (Proposals: 101035[82], 120839[83], 130776[84])
• Ovarian Cancer: In the 45 years since the War on Cancer was declared, ovarian cancer mortality rates have not significantly improved. According to the American Cancer Society, it is estimated that in 2017, more than 22,400 American women will be diagnosed with ovarian cancer, and approximately 14,080 will lose their lives to this terrible disease.  Ovarian cancer is the fifth leading cause of cancer death in women.  Currently, more than half of the women diagnosed with ovarian cancer will die within five years.  Of the 850,000 female service members, wives of active duty military and adult daughters of active duty military[85], approximately 11,800 will be diagnosed with ovarian cancer over the course of their lifetimes. [86]  Over a five-year period, nearly 2,600 members of our military or their families may be hospitalized for ovarian cancer or suspected ovarian cancer. The cost of ovarian cancer to our military is great, not only in terms of troop readiness, but also in terms of cancer care costs: treating these cases of ovarian cancer over these patients’ lifetimes could cost TRICARE an estimated $971.2 million. [87] TRICARE’s potential costs to care for women with ovarian cancer could fund the Ovarian Cancer Research Program at the Department of Defense for nearly 50 years at its current funding level.
• Pancreatic Cancer: Research has shown that there is direct evidence for excessive risk of death from pancreatic cancer in some US veterans. Specifically, nurses serving in Vietnam had a 2 to 5-fold higher risk of pancreatic cancer death compared with non-deployed US military women. [88][89] The reasons for this increase may be related to environmental exposures such chemical agents used in the field or in medical facilities, an association with predisposing medical conditions such as diabetes, and/or lifestyle propensities such as smoking, all which include known risk factors for pancreatic cancer. [90][91]  Further, the link between type 2 diabetes and pancreatic cancer is well-established[92] and type 2 diabetes is recognized by the VA as an Agent Orange-associated presumptive disease.[93]  The Peer Reviewed Cancer Research Program has funded a variety of critical research areas since pancreatic cancer was first included in 2011, including investigations into biomarkers to detect pancreatic cancer early or follow response to therapy, targeting the oncogene KRAS, activating the immune system, taking advantage of metabolic differences between normal and malignant pancreas cells, and a variety of highly novel therapeutic approaches.  Continued support for this research is critical not only for the potential risks for developing pancreatic cancer associated with military service, but also because pancreatic cancer is currently the nation’s third leading cause of cancer-related death and is predicted to surpass colon cancer to become second only to lung cancer by the year 2020.[94]
• Parkinson’s research program: Parkinson’s Disease (PD) environmental risk factors overlap common soldier occupational exposures such as traumatic brain injury and neurotoxic chemical exposures.  The combination of brain injury and chemical exposure triple Parkinson’s risk.[95]  In 2012, the Department of Veterans’ Affairs (VA) made PD presumptive for TBI-connected with military service[96] and secondary service connection for diagnosable illnesses associated with traumatic brain injury.[97]  The Neurotoxin Exposure Treatment (Parkinson’s) Research Program (NETPR) is funding studies in biomarkers of TBI and PD.  Environmental and occupational chemical exposures, notably pesticides, increase the risk of PD in service members and has also been a focus of NETPR, identifying organochlorine compounds previously used in agriculture, environmental PCBs, and permethrin used in Army uniforms as risk factors for PD.[98]   Parkinson’s Disease Research, Education, and Clinical Centers (PADRECCs) were established within six leading VA centers to provide treatment to veterans with PD; research in these centers has benefited from NETPR program grants and provides transition between active duty members diagnosed with PD and their state-of-the-art continuity of care for PD in the VA. PD also shares neurological effects of concerns to soldiers such as disrupted sleep, depression, and cognitive impairment.  All of these “dual use” aspects that are relevant to soldiers and to the PD community and have been a focus of NETPR.
• Prostate Cancer: Prostate cancer is the second deadliest cancer among American men, killing more than 26,000 men annually,[99] and there are more than 1.5 million prostate cancer patients in the U.S. that depend on breakthroughs in research to continue their fight. Prostate cancer significantly impacts both active duty servicemen, veterans, and their families; in fact, active duty males are twice as likely to be diagnosed with prostate cancer as their civilian counterparts,[100] with negative effects on their ability to serve. In addition, soldiers exposed to chemical agents such as Agent Orange in Vietnam are considered to be at increased risk of death from prostate cancer due to its association with high-grade disease in a population-based study of US Veterans.[101]  Research funded by the Prostate Cancer Research Program (PCRP) advances treatments; PCRP funding was responsible for accelerating the development of the two most impactful new treatments for advanced disease in the last four years,[102] [103] bringing them to patients faster than typical development of new drugs. Moreover, the program focuses on not only developing more effective therapeutics but also on improving diagnosis to reduce over treatment and accurately distinguish life-threatening disease from indolent tumors,[104]  which is likely to have its greatest impact on active duty servicemen who can be confidently monitored through active surveillance,[105]  rather than compromising their service to undergo treatment.
• Sleep: Insufficient sleep and sleep disorders affect the health of an estimated 70 million Americans across all demographic groups, including military personnel. Sleep disruption, especially insomnia, is a contributing risk factor to the onset and severity of major mental health problems such as depression, bipolar disorder, substance abuse, posttraumatic stress disorder, traumatic brain injury, and suicide. [106] [107] [108] [109] [110] An increasingly detrimental condition affecting military troops is sleep-disordered breathing, including obstructive sleep apnea which results in excessive daytime somnolence, poor performance, increased frequency of road traffic accidents, and arterial hypertension.[111]

Studies show that 85{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of 725 troops returning home from Afghanistan and Iraq had a sleep disorder and the most common was obstructive sleep apnea (51{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d}).If left untreated, obstructive sleep apnea has significant negative impacts on health, including early mortality. By using continuous positive airway pressure (CPAP), a treatment used to combat sleep apnea, military personnel report reductions in pain and fatigue, and improvements in cognitive function. [112]  The high prevalence of sleep and circadian disturbances indicates an opportunity for research advances and informed public policy to reduce disease risk across a lifespan and improve the health of our active troops. It is important to accelerate scientific discovery of the relationship between mental health, overall health and sleep and circadian disorders, and strengthen cognitive function and military readiness through the improvement of sleep quality.

• Tuberculosis (TB): TB is the single largest infectious disease killer globally and represents 30 percent of deaths from antimicrobial resistant bacteria. TB (and growing drug resistance) presents a serious concern for the US military. TB is currently endemic (incidence rate greater than 20 cases per 100,000 population) in 145 countries across the world[113] and 98 of these countries are areas of interest to the US Department of Defense (DoD)—either locations where US military personnel are already stationed, or regions where deployment probability is high.[114]  During deployment, the warfighter could be exposed to M tuberculosis bacteria and could develop either latent or active TB in either drug sensitive (DS) or, much more ominously, drug resistant (DR) forms. In 2014, an estimated 1.7 billion individuals worldwide were thought to be carriers of latent TB bacteria.[115]  Over a lifetime, around 10 percent of LTBI cases will progress to infectious TB.[116]  LTBI’s pervasiveness in the global population should be a primary concern for TB diagnoses in the US military. Already, between 2008 and 2012, most active TB cases (57.9 percent) diagnosed at accession in the US military were associated with an existing LTBI.[117]  While the healthy warfighter may not activate a latent TB infection immediately, risk increases for people under significant stress and for immunocompromised individuals.[118]  Further, veterans will be at increased risk of activating a latent TB infection as they age and develop co-morbid health conditions—creating a public health risk in the US. Perhaps the most serious TB concern facing the US military—and the broader global population—is the increase in drug resistant TB. While there are serious shortcomings in available treatment options for all forms of TB, for DR-TB it is especially problematic and worrisome. Even an MDR-TB outbreak in the US could have serious consequences given the costs associated with treatment. The cost to treat and care for a patient with TB in the US averages $17,000 for drug-susceptible TB, $150,000 for MDR-TB, and $482,000 for XDR-TB. Further, the lasting side effects of present DR-TB treatment can be devastating, including deafness, kidney damage, depression or psychosis.[119]   An increase in the number of patients with MDR-TB or XDR-TB would have a devastating financial impact on state and local health-care systems and on the ever-growing cost of DoD personnel and veteran’s care.[120]
• Tuberous Sclerosis Complex (TSCRP): Research supported by the TSCRP is paving the way to finding cures and treatments for individuals with TSC as well as those with other neurological disorders like epilepsy and autism spectrum disorder (ASD).  Research through TSCRP award W81XWH-12-1-0190[121] developed a mouse model for TSC, which in addition to its use for studying epilepsy and autism, is helping understand the consequences and potential treatment for post-traumatic brain injury (TBI) – a disorder of grave concern to the U.S. Armed Services. In 2016, the last year for which complete data are available, there were more than 18,311 documented traumatic brain injuries in the U.S. military.[122]  A more recent award, W81XWH-14-1-0061, is testing existing FDA-approved drugs for their ability to treat or prevent epilepsy by regulating the biochemical pathway shared between TSC and TBI.  Many other TSCRP awards enabled these key studies by generating the knowledge about this shared biochemical pathway.  Some of the awards that built this foundation of knowledge include DAMD17-03-1-0073[123], W81XWH-04-1-0309[124], W81XWH-06-1-015[125], W81XWH-09-1-0088[126], W81XWH-10-1-0861[127], W81XWH-13-1-0040[128].
• Vision: Vision, the sense most critical for optimal military performance in battlefield and support positions, is vulnerable to acute and chronic injury.  Research to effectively treat vision trauma and TBI-related visual disorders can have long-term implications for an individual’s vision health, productivity, and quality of life for the remainder of military service and into civilian life.  Traumatic eye injury from penetrating wounds and TBI-related visual disorders ranks second only to hearing loss as the most common injury among “active” military, accounting for upwards of 16 percent of all injuries in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Go through Winnipeg optometrists for the best eye care solutions.The VHA reports 202,000 OEF/OIF veterans with eye injuries since 2000 [130], as well as that upwards of 75 percent of all TBI patients experience short- or long-term visual disorders (double vision, light sensitivity, inability to read print, and other cognitive impairments).  A 2012 study using published data from 2000-2010 estimated that deployment-related eye injuries and blindness have cost the U.S. $2.3 billion a year, yielding a total of $25.1 billion, driven primarily by the present value of long-term benefits, lost wages, and family care.[131]

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