Caring for Veterans with Cancer

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:09Welcome to Yale Cancer Answers
00:09 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features
00:12 --> 00:14the latest information on cancer
00:14 --> 00:15care by welcoming oncologists and
00:15 --> 00:18specialists who are on the forefront
00:18 --> 00:20of the battle to fight cancer.
00:20 --> 00:21This week, it's a conversation
00:21 --> 00:23about the care of veterans with
00:23 --> 00:25cancer with Doctor Michal Rose.
00:25 --> 00:27Dr. Rose is a professor of medicine
00:27 --> 00:29and director of the West Haven
00:29 --> 00:31VA Comprehensive Cancer Center,
00:31 --> 00:32and Doctor Chagpar is a professor
00:32 --> 00:34of surgical oncology at the
00:34 --> 00:35Yale School of Medicine.
00:36 --> 00:38So Michal, maybe we can start off
00:38 --> 00:40by you telling us a little bit more
00:40 --> 00:42about yourself and what it is you do.
00:42 --> 00:45Sure. I'm originally from Israel.
00:45 --> 00:47That's where I went to medical school
00:47 --> 00:50and I did my residency training there.
00:50 --> 00:53I came to the United States in 1993,
00:53 --> 00:55so it's been almost 30 years.
00:55 --> 00:57And I did my training in hematology,
00:57 --> 00:59oncology here at Yale.
00:59 --> 01:00And during that training,
01:00 --> 01:03I really fell in love with the VA hospital,
01:03 --> 01:05the veterans and the whole system.
01:05 --> 01:08So I was thrilled when the opportunity
01:08 --> 01:11came up to take a job there in 1999,
01:11 --> 01:14and I've been there ever since.
01:14 --> 01:16I rose through the academic ranks
01:16 --> 01:18to become a full professor in
01:18 --> 01:20the section of medical oncology,
01:20 --> 01:23and I've been section Chief of
01:23 --> 01:28Hematology oncology at the VA since 2005.
01:28 --> 01:30So while my areas of interest
01:30 --> 01:32really have focused on, of course,
01:32 --> 01:34the cancers that are seen
01:34 --> 01:36commonly in veterans,
01:36 --> 01:39I'm also very interested in systems of care,
01:39 --> 01:42so practicing in the VA system
01:42 --> 01:44has really made me interested
01:44 --> 01:47in efficient use of resources,
01:47 --> 01:48care coordination,
01:48 --> 01:51and really streamlining care for
01:51 --> 01:54people with cancer and complex
01:54 --> 01:57medical and psychosocial needs which
01:57 --> 01:59are very common in our population.
02:00 --> 02:01So there's a few things that
02:01 --> 02:03I want to pick up on on that.
02:03 --> 02:06So the first is, can you tell us a little
02:06 --> 02:09bit more about what are the cancers that
02:09 --> 02:11are particularly common in veterans?
02:11 --> 02:13And are they different from those that
02:13 --> 02:15are common in the rest of the population?
02:16 --> 02:18Well, as I'm sure you know,
02:18 --> 02:21the majority of veterans are still men,
02:21 --> 02:23although we are seeing an increase
02:23 --> 02:25in women veterans as more and
02:25 --> 02:27more women serve in the military.
02:27 --> 02:30But because our population is mainly men,
02:30 --> 02:34we see cancers that are common in men,
02:34 --> 02:36which are mainly prostate
02:36 --> 02:38cancer and lung cancers.
02:38 --> 02:42We also see cancers of the bladder,
02:42 --> 02:43skin, Melanoma,
02:43 --> 02:46kidney cancer and liver cancers,
02:46 --> 02:48and those are probably
02:48 --> 02:51our most common cancers.
02:51 --> 02:56I will say that the VA is a leader in
02:56 --> 02:59cancer screenings and early detection.
02:59 --> 03:00So as a result,
03:00 --> 03:02we really diagnose many of these
03:02 --> 03:05cancers at an early curable stage,
03:05 --> 03:06which is wonderful.
03:06 --> 03:08But of course the patients that are
03:08 --> 03:10referred to us in medical oncology
03:10 --> 03:13tend to have the more advanced stages
03:13 --> 03:15of these cancers that I mentioned.
03:16 --> 03:19So a few things,
03:19 --> 03:21are there particular cancers
03:21 --> 03:24that we see more commonly after
03:24 --> 03:28veterans have been exposed to either
03:28 --> 03:30chemical warfare or radiation?
03:30 --> 03:32I mean, we think about things
03:32 --> 03:35like Agent Orange and so on.
03:35 --> 03:37Can you talk a little bit about
03:37 --> 03:39whether we're seeing increases in
03:39 --> 03:41particular cancers among veterans
03:41 --> 03:43based on their occupation?
03:44 --> 03:46Absolutely, we're
03:46 --> 03:49learning more and more that exposures
03:49 --> 03:52that our veterans sustained
03:52 --> 03:54during their military service really
03:54 --> 03:58has a huge impact on their health
03:58 --> 04:01all throughout their life and
04:01 --> 04:04that really does include cancers.
04:04 --> 04:08You mentioned Agent Orange,
04:08 --> 04:10which is a huge risk factor for
04:10 --> 04:13cancer among the veterans of the
04:13 --> 04:16Vietnam War and the Vietnam War era.
04:16 --> 04:18And actually recently several new
04:18 --> 04:22conditions have been added to the list
04:22 --> 04:25of Agent Orange related malignancies.
04:25 --> 04:27So one of those which I'll
04:27 --> 04:29mention is not a cancer,
04:29 --> 04:32but it's a precancerous condition
04:32 --> 04:34called monoclonal gammopathy
04:34 --> 04:37of undetermined significance.
04:37 --> 04:41Or people may have heard of the term mgus
04:41 --> 04:45which is a precancerous condition which may
04:45 --> 04:49lead to myeloma and other blood disorders.
04:50 --> 04:51Lung cancer is very high
04:51 --> 04:53up there on the list,
04:53 --> 04:55and prostate cancer.
04:55 --> 04:59So two of the most common cancers in veterans
04:59 --> 05:02are related to Agent Orange exposure.
05:02 --> 05:05The other thing I'll mention about
05:05 --> 05:07Agent Orange is that the VA has
05:07 --> 05:09recently recognized that it wasn't
05:09 --> 05:12only the veterans that were in
05:12 --> 05:14Vietnam were exposed to Agent Orange,
05:14 --> 05:18so Agent Orange was stored
05:18 --> 05:21in multiple locations in the United States,
05:21 --> 05:23for example, military bases in
05:23 --> 05:25Florida and Maryland and others,
05:25 --> 05:27and outside the United States,
05:27 --> 05:29Canada, Cambodia, Thailand,
05:29 --> 05:32Korea and other sites.
05:32 --> 05:35And so the VA does recognize
05:35 --> 05:38now that veterans who
05:38 --> 05:41were exposed to Agent Orange may have just
05:41 --> 05:44served on those bases that I mentioned.
05:45 --> 05:49And one of the things that you
05:49 --> 05:52mentioned was that the VA has a
05:52 --> 05:55really robust program of screening.
05:55 --> 05:56So a couple of questions.
05:56 --> 06:00One, for the cancers that are most
06:00 --> 06:02commonly detected among veterans,
06:02 --> 06:04can you talk a little bit more
06:04 --> 06:05about the screening programs
06:05 --> 06:07that are available to them?
06:09 --> 06:12I think maybe I'll focus on lung cancer,
06:12 --> 06:15although of course prostate cancer
06:15 --> 06:20also is a cancer that we do screen for.
06:20 --> 06:22We know that the screening for prostate
06:22 --> 06:25cancer is a little bit more controversial,
06:25 --> 06:28and in fact some of the important
06:28 --> 06:30studies about screening for prostate
06:30 --> 06:32cancer were done in the VA system.
06:32 --> 06:34But when you look at lung cancer,
06:34 --> 06:37that's one of the newest cancers
06:37 --> 06:41that we now screen for and it
06:41 --> 06:43turns out that it's
06:43 --> 06:45actually quite complicated
06:45 --> 06:48to screen for lung cancer because
06:48 --> 06:50it's easy enough to do a quick
06:50 --> 06:52cat scan in someone at risk,
06:52 --> 06:55if they have smoked
06:55 --> 06:57a certain amount of cigarettes
06:57 --> 07:00within the last 15 years.
07:00 --> 07:03But it turns out that you need a whole
07:03 --> 07:06system of care to follow up on those
07:06 --> 07:07cat scans.
07:07 --> 07:10And that's where the VA really excels
07:10 --> 07:14because it is such a system of care.
07:14 --> 07:16And so the VA is a leader in
07:16 --> 07:18screening for lung cancer.
07:18 --> 07:19And in fact,
07:19 --> 07:22there's a national program which
07:22 --> 07:26we're participating in that is seeking
07:26 --> 07:30to structure that system with
07:30 --> 07:34templates and algorithms and
07:34 --> 07:36make sure that people who do get
07:36 --> 07:38screened come back for their follow-up
07:38 --> 07:40tests and their follow-up screening.
07:40 --> 07:43So that's really a very exciting
07:43 --> 07:47field that I feel the VA has a lot
07:47 --> 07:50to offer here in VA Connecticut.
07:50 --> 07:52We were one of the first
07:52 --> 07:54VA's one of the first sites in the
07:54 --> 07:56country to screen for lung cancer and
07:56 --> 07:59we have already screened thousands and
07:59 --> 08:01thousands of veterans and picked up
08:01 --> 08:04many lung cancers at an early stage.
08:05 --> 08:08For the screening for lung cancer,
08:08 --> 08:10you mentioned that Agent Orange
08:10 --> 08:13would put veterans at risk,
08:13 --> 08:16but yet many of the screening protocols,
08:16 --> 08:16as you mentioned,
08:16 --> 08:18are really based on smoking history.
08:18 --> 08:21Is there an exception for people who
08:21 --> 08:23don't meet the smoking threshold but
08:23 --> 08:25may have been exposed to various agents
08:25 --> 08:28that would also put them at risk?
08:28 --> 08:31No, we're not there yet.
08:31 --> 08:35I think that's a field of active research.
08:35 --> 08:36How do you incorporate other
08:36 --> 08:38risk factors for lung cancer?
08:38 --> 08:41We know a lot about smoking,
08:41 --> 08:42but like you mentioned,
08:42 --> 08:45there's many other risk factors,
08:45 --> 08:49but we don't have enough data yet to
08:49 --> 08:52incorporate those exposures into our
08:52 --> 08:53screening algorithms.
08:53 --> 08:58So I would say the answer to that is no,
08:58 --> 09:01although we definitely make exceptions
09:01 --> 09:05when veterans have had a very
09:05 --> 09:08heavy exposure to Agent Orange.
09:08 --> 09:11Perhaps this is an opportunity also to
09:11 --> 09:14mention some other exposures that we know
09:14 --> 09:18veterans sustain in their military service.
09:18 --> 09:21I don't know people have heard of
09:21 --> 09:23the problem with water
09:23 --> 09:25contamination in Camp Lejeune.
09:25 --> 09:28So Camp Lejeune is a Marine Corps base,
09:28 --> 09:31as it's located in North Carolina.
09:31 --> 09:33Sadly, between the years of
09:33 --> 09:36the 1950s to the 1980s
09:36 --> 09:39the drinking water there was
09:39 --> 09:40contaminated by solvents,
09:40 --> 09:43by benzene, and those are known
09:43 --> 09:44risk factors for leukemias,
09:44 --> 09:46for other bone marrow disorders,
09:46 --> 09:49for lymphomas, bladder cancer, kidney cancer,
09:49 --> 09:52liver cancer and probably lung cancer.
09:52 --> 09:56And so that is another very important
09:56 --> 09:59exposure that veterans sustain.
10:00 --> 10:01I will mention one other
10:03 --> 10:05exposure that has also been in the
10:05 --> 10:07news and the VA is addressing more and
10:07 --> 10:09more and that's the burn pits, right,
10:09 --> 10:14the burn pits that were used to destroy
10:14 --> 10:16basically garbage, military equipment
10:18 --> 10:22in Afghanistan and Iraq.
10:22 --> 10:25Caused huge amount of airborne toxins
10:25 --> 10:28that our veterans who resided in
10:28 --> 10:32those military bases were exposed to.
10:32 --> 10:34And some of you may have heard
10:34 --> 10:36of the PACT act
10:36 --> 10:39which was signed by the President just
10:39 --> 10:41last August and it really expanded
10:41 --> 10:44healthcare and benefits for veterans
10:44 --> 10:46exposed to many of these conditions,
10:46 --> 10:50including with an emphasis on burn pits.
10:50 --> 10:52And I do think the Pact act is going to
10:52 --> 10:53really increase the number of veterans
10:53 --> 10:56we take care of in the next few years.
10:57 --> 10:59Do those benefits and those
10:59 --> 11:02exposures affect veterans families
11:02 --> 11:05as well as the veterans themselves?
11:05 --> 11:09I mean, if we're thinking about
11:09 --> 11:12exposures that may affect entire communities.
11:12 --> 11:15One would imagine that anybody
11:15 --> 11:19who's on that base, whether it's
11:19 --> 11:23the veteran themselves or others,
11:23 --> 11:25would equally be exposed.
11:25 --> 11:26Is that right?
11:27 --> 11:30That is probably correct.
11:30 --> 11:35There is not really a recognition
11:35 --> 11:39that veterans families who develop cancer
11:39 --> 11:43are these maybe secondary to those exposures?
11:43 --> 11:46There is some recognition of other
11:46 --> 11:49conditions like birth defects in
11:49 --> 11:51children of veterans for example
11:51 --> 11:54are recognized and that again is a
11:54 --> 11:57whole field of very active research.
11:57 --> 12:01I will also mention that the VA cares for
12:01 --> 12:04veterans but rarely for veterans families.
12:04 --> 12:06So in that regard it is different
12:06 --> 12:08than other healthcare systems.
12:09 --> 12:13You know one of the things that you
12:13 --> 12:16mentioned and both in terms of
12:16 --> 12:19why you were attracted to the VA to
12:19 --> 12:22begin with as well as some of the
12:22 --> 12:24benefits that you've seen is really
12:24 --> 12:27the system that they have.
12:27 --> 12:30So can you talk a little bit more about
12:30 --> 12:32what are the components of the system
12:32 --> 12:36of the VA that you think makes it more
12:36 --> 12:39robust in terms of screening and offerings?
12:42 --> 12:46Well, I think there are several components.
12:46 --> 12:48The VA is the largest healthcare
12:48 --> 12:50system in the country.
12:50 --> 12:53It is an integrated system.
12:53 --> 12:56The VA has the oldest electronic
12:56 --> 12:59medical record in the country,
12:59 --> 13:03so way before most healthcare systems
13:03 --> 13:06had an electronic medical record
13:06 --> 13:09we were already using this
13:09 --> 13:12program called Vista and that
13:12 --> 13:14has a huge amount of benefits
13:14 --> 13:17so it unites the whole system.
13:17 --> 13:20So if a veteran gets care in Florida
13:20 --> 13:21and then moves to Connecticut,
13:21 --> 13:26I have no problem looking up that data.
13:26 --> 13:27So that helps.
13:27 --> 13:30It also enables streamlining a
13:30 --> 13:33lot of tasks using reminders.
13:33 --> 13:35It enables data gathering
13:35 --> 13:38and also a lot of it is
13:38 --> 13:41when you have a veteran who
13:41 --> 13:45is going to be in your system for life,
13:45 --> 13:48there is a strong incentive to
13:48 --> 13:52implement preventive care measures
13:52 --> 13:55because you will as a healthcare
13:55 --> 13:58system reap those benefits.
13:58 --> 14:04So I think that also helped
14:04 --> 14:06push the field forward.
14:08 --> 14:10Part of the mission of the VA
14:10 --> 14:12is good care, right?
14:12 --> 14:15Preventive care is good care.
14:15 --> 14:17The VA has had a huge emphasis
14:17 --> 14:20on primary care, which is
14:20 --> 14:23really the bedrock of preventive care of
14:23 --> 14:29screening for cancers and other conditions.
14:29 --> 14:32And there's also, in the culture,
14:32 --> 14:35we are very much
14:35 --> 14:37encouraged to come up with
14:37 --> 14:40efficiencies, with systems,
14:40 --> 14:43with quality improvements,
14:43 --> 14:46and that's a huge part of the culture at the VA.
14:46 --> 14:49So those are probably the main reasons.
14:49 --> 14:52But when you look at studies about
14:52 --> 14:55successive cancer screening, the VA is
14:55 --> 14:58almost always sort of at
14:58 --> 15:01the top of the list of percent
15:02 --> 15:03veterans
15:03 --> 15:06screened and guidelines followed.
15:07 --> 15:09All really good points.
15:09 --> 15:11We need to take a short break for
15:11 --> 15:13a medical minute, but we'll pick
15:13 --> 15:15up this story on the other side,
15:15 --> 15:17learning more about caring for our
15:17 --> 15:19veterans with Doctor Michal Rose.
15:20 --> 15:22Funding for Yale Cancer Answers
15:22 --> 15:24comes from Smilow Cancer Hospital,
15:24 --> 15:26where their cancer genetics and
15:26 --> 15:27prevention program includes
15:27 --> 15:29a colon cancer genetics and
15:29 --> 15:31prevention program that provides
15:31 --> 15:32comprehensive risk assessment,
15:32 --> 15:35education and screening.
15:35 --> 15:36Smilowcancerhospital.org.
15:38 --> 15:40Genetic testing can be useful for
15:40 --> 15:42people with certain types of cancer
15:42 --> 15:43that seem to run in their families.
15:43 --> 15:46Genetic counseling is a process that
15:46 --> 15:48includes collecting a detailed personal
15:48 --> 15:50and family history, a risk assessment,
15:50 --> 15:53and a discussion of genetic testing options.
15:53 --> 15:56Only about 5 to 10% of all
15:56 --> 15:57cancers are inherited,
15:57 --> 15:59and genetic testing is not recommended
15:59 --> 16:02for everyone. Individuals who have a
16:02 --> 16:04personal and or family history that
16:04 --> 16:07includes cancer at unusually early ages,
16:07 --> 16:07multiple relatives
16:07 --> 16:09on the same side of the
16:09 --> 16:11family with the same cancer,
16:11 --> 16:13more than one diagnosis of
16:13 --> 16:15cancer in the same individual,
16:15 --> 16:16rare cancers,
16:16 --> 16:19or family history of a known altered
16:19 --> 16:21cancer predisposing gene could be
16:21 --> 16:23candidates for genetic testing.
16:23 --> 16:25Resources for genetic counseling and
16:25 --> 16:27testing are available at federally
16:27 --> 16:29designated comprehensive cancer centers,
16:29 --> 16:31such as Yale Cancer Center
16:31 --> 16:33and Smilow Cancer Hospital.
16:33 --> 16:35More information is available
16:35 --> 16:36at yalecancercenter.org.
16:36 --> 16:38You're listening to Connecticut.
16:38 --> 16:39Public radio.
16:40 --> 16:42Welcome back to Yale Cancer Answers.
16:42 --> 16:44This is doctor Anees Chagpar
16:44 --> 16:46and I'm joined tonight by my guest,
16:46 --> 16:47Doctor Michal Rose.
16:47 --> 16:49We're talking about care
16:49 --> 16:50of veterans with cancer.
16:50 --> 16:53And right before the break,
16:53 --> 16:56you were telling us about some of
16:56 --> 16:58the advantages of the VA system
16:58 --> 17:00that you think leads to
17:00 --> 17:02higher rates of screening and so on.
17:02 --> 17:05One of which is that it's
17:05 --> 17:06an integrated system.
17:06 --> 17:09So all of the care is offered
17:09 --> 17:10under one system.
17:10 --> 17:13There's the longest running
17:13 --> 17:15electronic health record system
17:15 --> 17:18which really is not just in one
17:18 --> 17:21system but across the country.
17:21 --> 17:23So if a veteran is treated in
17:23 --> 17:25Florida and moves to Connecticut,
17:25 --> 17:28you can still view all of those records.
17:28 --> 17:32There's a strong incentive to really
17:32 --> 17:36keep veterans healthy and a
17:36 --> 17:39strong emphasis on preventative care.
17:39 --> 17:41And I think the other thing
17:41 --> 17:43that we didn't mention is that
17:43 --> 17:46all of the care is done under one roof.
17:46 --> 17:48Veterans in general get all
17:48 --> 17:50of their care at the VA.
17:50 --> 17:52They don't kind of get part of
17:52 --> 17:54their care at the VA and part of
17:54 --> 17:55their care at different hospitals
17:55 --> 17:57and different doctor's offices.
17:57 --> 17:58So, you know,
17:58 --> 18:01as we think about the lessons
18:01 --> 18:03learned from the VA system,
18:03 --> 18:06I want to kind of pick your brain about
18:06 --> 18:09what might be policy implications with
18:09 --> 18:12regards to the rest of the healthcare system?
18:13 --> 18:15You mentioned right before the
18:15 --> 18:18break that in the VA system there
18:18 --> 18:20is an emphasis on efficiency
18:20 --> 18:22and best practice and yet we know
18:22 --> 18:25that in general the US healthcare
18:25 --> 18:27system lacks that efficiency.
18:27 --> 18:29We tend to be a very expensive system
18:29 --> 18:33and we don't tend to get the same health
18:33 --> 18:35outcomes that one would anticipate
18:35 --> 18:38for the amount of money that we spend.
18:38 --> 18:42Can you talk a little bit about what you
18:42 --> 18:47think might be some things that
18:47 --> 18:48the federal government
18:48 --> 18:50might want to consider
18:50 --> 18:52in terms of healthcare reform,
18:52 --> 18:54which is always something that
18:54 --> 18:56people are thinking about,
18:56 --> 18:58especially when they think about
18:58 --> 19:01how we can cut the deficit and,
19:01 --> 19:02you know, improve,
19:02 --> 19:04healthcare at the same time.
19:05 --> 19:07Yes. Well, thank you for that question.
19:07 --> 19:10I don't know if I have all the answers,
19:10 --> 19:14but after working in the VA system for
19:14 --> 19:18more than 20 years and of course being very
19:18 --> 19:20aware of what happens in other systems,
19:20 --> 19:22there are some obvious
19:22 --> 19:24improvements that we could make.
19:24 --> 19:27And a lot of them have been
19:27 --> 19:29recognized and are happening maybe
19:29 --> 19:32not as fast as we would like.
19:32 --> 19:34For example, the electronic medical record
19:34 --> 19:36of course is now adopted and pretty
19:36 --> 19:39much I think every healthcare system in
19:39 --> 19:41the country and there's a requirement,
19:41 --> 19:43I think a federal requirement that
19:43 --> 19:46these systems talk to each other,
19:46 --> 19:50so that more and more we are able to
19:50 --> 19:53see what's happening to our patients
19:53 --> 19:54in other systems.
19:54 --> 19:58So that is happening and hopefully
19:58 --> 20:01will continue to improve and that
20:01 --> 20:04process should be streamlined.
20:04 --> 20:07The emphasis on primary care and
20:07 --> 20:09preventive care is very important
20:12 --> 20:13but that is a complicated one.
20:13 --> 20:16We have a shortage of primary
20:16 --> 20:20care doctors and nurse
20:20 --> 20:21Practitioners and PFAS,
20:21 --> 20:22et cetera.
20:22 --> 20:24That is a field that we should expand.
20:25 --> 20:27These amazing practitioners should
20:27 --> 20:31be rewarded for their hard work
20:31 --> 20:33and they should be supported.
20:33 --> 20:36The other thing is to invest
20:36 --> 20:37in supportive services.
20:37 --> 20:42the VA has a huge number of social workers,
20:42 --> 20:44for example,
20:44 --> 20:47those incredibly valuable resources.
20:47 --> 20:51The VA offers travel assistance to veterans.
20:51 --> 20:52That's very important because
20:52 --> 20:54often that is the barrier.
20:54 --> 20:56People can't get to their appointments
20:56 --> 21:00and the VA does recognize that and
21:00 --> 21:03has every hospital has a travel
21:03 --> 21:05department and that is a benefit
21:05 --> 21:07for many of the veterans.
21:07 --> 21:09Another big thing is drug cost, right?
21:09 --> 21:12So the VA covers drug costs.
21:12 --> 21:15Veterans get pretty much all
21:15 --> 21:17their drugs free or cheap.
21:17 --> 21:18So they take them.
21:18 --> 21:21If a patient can't afford their medication,
21:21 --> 21:24they're not going to take them.
21:24 --> 21:26And then the consequences are
21:26 --> 21:29bad for the patient and of course
21:29 --> 21:32for the healthcare system.
21:32 --> 21:34So that's another huge thing that I
21:34 --> 21:38know we are all aware of the cost of
21:38 --> 21:41drugs and their availability to our patients.
21:41 --> 21:46Taking each of those factors
21:47 --> 21:49when you think about primary
21:49 --> 21:52care and I agree with you,
21:52 --> 21:58having a primary care as a gatekeeper or a
21:58 --> 22:02Segway to various specialists often is very
22:02 --> 22:05efficient as opposed to having
22:05 --> 22:07chest pain, going to a cardiologist,
22:07 --> 22:10having them tell you no it's not your heart,
22:10 --> 22:13and then going to a pulmonologist and
22:13 --> 22:16them telling you no, it's not your lungs.
22:16 --> 22:18And then going to a gastroenterologist
22:18 --> 22:20and having them tell you no,
22:20 --> 22:22it's not your GI system,
22:22 --> 22:25only to find out later that it might
22:25 --> 22:28have been related to something
22:28 --> 22:31you know, extraneous.
22:31 --> 22:33Having a primary care
22:33 --> 22:36Doctor who can kind of do a very good
22:36 --> 22:39history and physical and work
22:39 --> 22:41things up might be very efficient.
22:41 --> 22:43My perception, however,
22:43 --> 22:46is that there is some reticence on
22:46 --> 22:49the part of the American public
22:49 --> 22:52to embrace a system with primary
22:52 --> 22:55care as a gatekeeper.
22:55 --> 22:58We've seen this in other systems of what's
22:58 --> 23:01commonly called, quote, socialized medicine.
23:01 --> 23:04I'm using air quotes here.
23:07 --> 23:10It seems to me that that is something that
23:10 --> 23:13not a lot of Americans really embrace.
23:13 --> 23:16Can you talk a little bit more about
23:17 --> 23:20whether you get pushback from veterans
23:20 --> 23:24who don't want to go through primary care?
23:24 --> 23:28Is there an obligation for them to do so?
23:28 --> 23:30How does that work?
23:32 --> 23:35Actually, I don't.
23:35 --> 23:38The VA does require every veteran
23:38 --> 23:42to have a primary care provider.
23:42 --> 23:43But you know,
23:43 --> 23:45you shouldn't call them gatekeepers.
23:45 --> 23:46These people are not,
23:46 --> 23:47that's not their main role.
23:47 --> 23:51Their role is to maintain and promote
23:51 --> 23:55the health of their patients and
23:55 --> 23:57the gatekeeping function is, I would say,
23:57 --> 24:02minor relative to all the other
24:02 --> 24:07benefits they can offer the patient.
24:07 --> 24:11But I also think that an efficient
24:11 --> 24:14system helps the patients, for example,
24:14 --> 24:17when we have an abnormal
24:17 --> 24:19cat scan of the chest,
24:19 --> 24:22we bring that scan to our
24:22 --> 24:24multidisciplinary forum, a tumor board,
24:24 --> 24:25and we decide right away where
24:25 --> 24:27this veteran is going to go.
24:27 --> 24:30Will they go directly to the surgeon?
24:30 --> 24:33Will they go to the oncologist or the
24:33 --> 24:36radiation therapist instead of the
24:36 --> 24:38veteran himself going from specialist
24:38 --> 24:41to specialist only to say, oh,
24:41 --> 24:43sorry, I can't do surgery or sorry,
24:43 --> 24:46this is not a tumor that's
24:46 --> 24:48conducive to radiation,
24:48 --> 24:52so you can't put together systems that help
24:52 --> 24:57the patient, him or herself and save money,
24:57 --> 24:59and that's really what we try and do
24:59 --> 25:02at the VA that's one of the things
25:02 --> 25:04I've really pushed for at my VA.
25:05 --> 25:07Yeah, I couldn't agree with you more.
25:07 --> 25:10You know, it seems to me that
25:10 --> 25:15the VA is a microcosm of kind of
25:15 --> 25:19universal healthcare in the sense
25:19 --> 25:23that VA offer veterans access.
25:23 --> 25:26You know, they're all covered.
25:26 --> 25:30There are multiple VA's around the country
25:30 --> 25:35that offer services and can do so in a
25:35 --> 25:37cost efficient manner,
25:37 --> 25:43do you think that as a country
25:43 --> 25:47it's something to consider in terms of
25:47 --> 25:52following the VA system for everybody
25:52 --> 25:54and expanding access to everybody
25:54 --> 25:57under a system kind of like the VA?
25:58 --> 26:02Well, I'm biased obviously I would say
26:02 --> 26:05yes you know healthcare systems are very
26:05 --> 26:06complex systems,
26:06 --> 26:11and there are pros and cons to every system.
26:11 --> 26:15Certainly there are plenty of
26:15 --> 26:17problems in the VA system too,
26:17 --> 26:22but overall I think I do believe that
26:22 --> 26:25having a system in which
26:25 --> 26:30the mission is more comprehensive care,
26:32 --> 26:36it is a not-for-profit and when
26:36 --> 26:39providers are mostly salaried and
26:39 --> 26:45not so much dependent on doing more
26:45 --> 26:48procedures is beneficial to everyone.
26:48 --> 26:51I think it saves money.
26:51 --> 26:53I think it most importantly
26:53 --> 26:57promotes the health of patients.
26:57 --> 26:59Yeah, certainly realigning
26:59 --> 27:02incentives is helpful.
27:02 --> 27:07One of the critiques that universal
27:07 --> 27:10healthcare systems like the VA,
27:10 --> 27:12like the Canadian healthcare system,
27:12 --> 27:17like the NHS have is that,
27:17 --> 27:21well a few criticisms, one is
27:21 --> 27:22prolonged wait times,
27:22 --> 27:25do you find that in the VA system?
27:25 --> 27:27So I can't speak for the
27:27 --> 27:29VA system as a whole.
27:29 --> 27:32Of course it's a huge healthcare system.
27:32 --> 27:34Like I said, the largest we
27:34 --> 27:36are required for example,
27:36 --> 27:37and this is every specialist,
27:37 --> 27:40to see a patient within 30 days.
27:40 --> 27:42If we cannot fit that
27:42 --> 27:44patient in within 30 days,
27:44 --> 27:47they are to be sent to the community.
27:47 --> 27:51We often find that when we send patients
27:51 --> 27:54out to the Community they wait 60
27:54 --> 27:57days and 90 days and longer so
27:57 --> 27:59actually being part
27:59 --> 28:01of a system where you are
28:01 --> 28:03required to provide access and
28:03 --> 28:06to see patients in a timely
28:06 --> 28:08fashion is very important.
28:08 --> 28:12Try getting an appointment for a
28:14 --> 28:16Dermatologist, subspecialist.
28:17 --> 28:21I know it's a complicated matter,
28:21 --> 28:25but I am very much in favor of a
28:25 --> 28:28system having benchmarks and holding
28:28 --> 28:30members accountable.
28:31 --> 28:33Doctor Michal Rose is a professor
28:33 --> 28:36of medicine and director of the West
28:36 --> 28:38Haven VA Comprehensive Cancer Center.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:52learn more about the fight against
28:52 --> 28:54cancer here on Connecticut Public Radio.
28:54 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Caring for Veterans with Cancer with guest Dr. Michal Rose March 5, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095