Cancer Answers: Cancer Care for Veterans, April 4, 2010

Dr. Michal Rose, Cancer Care for Veterans
April 4, 2010Welcome to Yale Cancer Center Answers with Dr. Ed Chu and
Dr. Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy
Director and Chief of Medical Oncology at Yale Cancer Center and
Dr. Foss is a Professor of Medical Oncology and Dermatology
specializing in the treatment of lymphomas.  If you would like
to join the conversation, you can contact the doctors
directly.  The address is canceranswers@yale.edu
andthe phone number is 1888-234-4YCC.  This
eveningFrancinewelcomes Dr. Michal Rose. 
Dr. Rose is theDirector of the West Haven VA Cancer
Center and is also an Associate Professor of Medicine at Yale
School of Medicine.  Here is Francine Foss.Foss
 Let's start off by having you tell us a little about the West
Haven VA Cancer Center and how it got started.Rose
 I have been at the cancer center for 10 years and we offer full
medical oncology services there. We offer chemotherapy, biological
therapy, surgical oncology services, and we have all the
sub-specialists in surgery, general surgery, urologic surgery,
chest surgery, head and neck, neurosurgery, and plastic.  The
only thing we do not have is radiation therapy.  We refer most
of our patients out either to Yale or to facilities near their
home.Foss
 Michal, could you describe for us what the relationship is between
Yale Cancer Center and the VA Medical Center?Rose
 We have a very close relationship actually. We are of course
academically affiliated, so all our faculty have academic
appointments at Yale, and we have a combined fellowship program and
residency program, so all the fellows rotate through the VA and it
is a big part of their training. Then of course the residents in
internal medicine and surgery all spend time at the VA and are
exposed to our work and cancer treatment, and also medical
students, PA students, you name it.  So, the relationship is
very close and on the research front, we participate in Yale
clinical trials; we are really considered one and part of the
cancer center.Foss
 You actually are considered one of the major faculty members in
the cancer center and you are the Director of the cancer operations
there.Rose
 That is correct.Foss
 But you also work with your colleagues in surgery, as you
mentioned, and are the surgeons at the VA Hospital also on the
faculty at Yale?Rose
 Yes, they all are.  One of the nice things about the VA is
that we are able to benefit from a big cancer center like Yale, so
on the surgical realm, we have fantastic surgeons, if we were2:48 into mp3 file 
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 just a small community hospital we would not have exposure to such
specialized surgeons, so that is a huge plus for us and for our
patients, of course.Foss
 Can you tell us who is eligible to come and get their care at the
VA Hospital?Rose
 All veterans who participated in active military service in the
Army, Navy, Air Force, Marines, or Coast Guard are eligible unless
they were discharged under dishonorable conditions, that is the
only exception.  We are now welcoming home our newest veterans
from Operation Enduring Freedom and Operation Iraqi Freedom. 
Once a veteran is enrolled in the VA system, he or she can receive
care at any VA facility in the country, even Puerto Rico.  It
is all one system.Foss
 Can you describe the other VA hospitals in the area, I understand
there are a couple in Massachusetts and in New York as well, how do
veterans decide which way to go?Rose
 It's usually related to where they live, of course, so it's
geographic.  We are the only cancer center and the only
inpatient facility for veterans in Connecticut.  Boston and
New York, of course, have facilities and there are outpatient
clinics within Connecticut, the largest outpatient facility is in
Newington and we do have clinics there for our veterans in
hematology and oncology.  Most of the veterans who live in
Connecticut come to us, and we even take care of some veterans from
Western Massachusetts, because it is a little closer for them.
 There are veterans who choose to come to us because we are a
full service cancer center and they come from New York and Rhode
Island.  We offer some services that are not available in
other VA's, especially surgical services, neurosurgery.  In
urology, we have the da Vinci Robot, so patients come to us for
that, but most of our population is from Connecticut.  I want
to take this opportunity to mention that VA Connecticut was ranked
number 1 among similar facilities in a bunch of clinical measures
recently, so that data just came out and we are very proud.Foss
 You should be proud for your strong work with the veterans. 
You have talked about a number of programs that are unique at the
medical center.  Can you talk about the integration of the VA
system overall? Do you work with the cancer programs and some of
the other VA Hospitals, or within the whole system in general?Rose
 Yes, I would say one of the strengths of the VA is the fact that
it is a national program and it is the largest health care provider
in the nation, and that is an opportunity to develop initiatives
and quality improvements that have a huge impact.  I have been
involved in several, what the VA calls collaboratives to improve
cancer care, one in colon and rectal6:00 into mp3 file 
http://www.yalecancercenter.org/podcast/apr0410-cancer-answers-rose.mp3
 cancer and one in lung cancer and teams from VA's all over the
country get together and work on system redesign and improving
care.  They measure various quality measures, compare and
share things that work, and things that do not work, so it is a
very effective system to improve care.Foss
 Most of us out there do not really appreciate the fact that the VA
system has probably one of the best patient care databases
anywhere.Rose
 That is correct.  The VA was one of the pioneers in
electronic medical record and we went electronic about 10 years ago
when I first started, and the VA has a fantastic electronic medical
record that is really the envy of all programs I would say. It is a
very effective way of monitoring quality measures and a very
powerful research tool.Foss
 Can you step back a little and tell our listeners what kind of
cancer you see.  What are the major things that are happening
in this population? Is it similar to the kinds of cancers that we
see at Yale Cancer Center?Rose
 I would say both similar and different. Our most common cancers
are prostate, lung, bladder, colorectal, and blood and lymph
cancers; the majority of our veterans are men.  Although that
is changing, of course with the younger veterans we are seeing more
and more women.  Unfortunately, a lot of our veterans smoke or
used to smoke, so we see a lot of smoking-related cancer, lung
cancer, bladder cancer, and head and neck cancer.  We are also
seeing an increasing number of liver cancers now among the
veterans, which is a trend nationwide.  The other thing that
is somewhat unique in the VA is that many of our Vietnam veterans
were exposed to Agent Orange.  It was the herbicide that was
used to remove the leaves from the trees in Vietnam between 1961
and 1971, and multiple cancers have been linked to this exposure;
lymphoma, some leukemias, sarcoma, myeloma, prostate cancer, lung
cancer, and larynx cancer.  In some cancers the link is strong
and in some cancers the link is unclear, but all these cancers that
I listed are recognized as conditions that have been linked to
Agent Orange and Veterans who suffer from these cancers and were
exposed to Agent Orange are also entitled to compensation regarding
that.Foss
 That is a very important point and we have in fact seen some of
those patients in our clinics, patients who have a service
connection for their lymphoma or for their cancer, and in those
cases we work very well with the VA to coordinate care for those
patients and sometimes they get some of their care at our facility,
and some of their care at your facility, so I think that needs to
be pointed out to the listening audience.Rose
 I agree Francine, we really feel that our veterans benefit from
our close relationship to Yale9:32 into mp3 file 
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 Cancer Center and all their expertise and experts.  We are
relatively small and have to be experts in everything, but at Yale
we have oncologists like yourself who can specialize in a few
cancers and develop research programs and really help patients get
the optimal state-of-the-art care. We often ask for advice from our
colleagues, we send patients over, and I think it is a very
beneficial relationship.Foss
 Can you tell us about the average age of your veterans now-a-days?
It used to be that most of our veterans were older because of World
War I, World War II, and Vietnam, but now we have had a number of
wars since then.  Are you starting to see younger people?Rose
 Yes, definitely. I do not know the exact number, but our World War
II vets, which were the largest number of veterans, are dying now
and have reached old age and the ones that are remaining are in
their 80s, late 80s even, and most of our veterans now are veterans
from the Vietnam or the Korean War who are in their 60s, and we are
starting to see, like I said, veterans from the most recent
conflict in their 20s, 30s, and 40s.  So there is a change in
the demographics.Foss
 You also mentioned that there is an increase in the number of
women coming through the VA system now, although there always were
women within the system, but have you seen changes in health care
delivery or changes in the programs that are offered at the VA to
account for the number of women that are now starting to come
through?Rose
 Definitely, the VA has always had, I should not say always, but
for many years there have been women centers in any large VA, and
we had women veterans from World War II and they served very
important functions, mostly as nurses, but there were other jobs
too. Certainly our current veterans are higher percentage
women.  Still in our clinics only a few percent, maybe up to
5% of our patients are women, but that is clearly changing and the
VA's across the nation are expanding their women centers and
offering more and more services for women.Foss
 Can you talk a little bit about some of the unique aspects that
veterans face when they have a diagnosis of cancer?Rose
 I think the diagnosis of cancer is devastating to anyone and it is
very very important for a patient to have a system set up to help
them cope with a new diagnosis, to help them go through the
complicated process of diagnosis, staging, and then treatment, and
I think that is true for every patient.  It is true that some
of our patients have mental illness or posttraumatic stress
disorder and that would probably make it even harder, and we are
very much aware of that and have a huge array of support systems to
help our veterans get the care they need.13:16 into mp3 file 
http://www.yalecancercenter.org/podcast/apr0410-cancer-answers-rose.mp3Foss
 Are some of the veterans more concerned now-a-days than they used
to be about the possibility of exposure, as you mentioned, to Agent
Orange or other chemicals that they are working with in the course
of their military experience, and the connection between that and
the cancers that they are developing?Rose
 There is much more awareness about the significance of these
exposures and there is a lot of research going on about potential
exposures that occurred during the Iraq and Afghanistan
conflicts.  I am not aware of any clear cut exposures related
to increased risk of cancer, but certainly it is very active field
of research.Foss
 In most of your cancer patients you mentioned other factors like
smoking.  To what degree does the VA have cancer prevention
programs for those kinds of issues?Rose
 The VA is actually a leader you could say in preventive
services.  We have a very active smoking cessation
program.  We monitor the effectiveness of our screaming for
all the cancers in which screening is indicated such as
colonoscopies for colon cancer, mammography for breast cancer, and
PSA checking with all the controversies.  All these are
monitored, and there is counseling of veterans to stop
smoking.  We have a very active program regarding weight loss
for obesity which is also a risk factor for cancer.  The VA
really leads the pack regarding effectiveness of compliance with
screening guidelines.Foss
 And perhaps that is a model for the rest of us as we move forward
with national health care proposals.  We are going to take a
break now for a medical minute. Please stay tuned to learn more
about the cancer services available at the VA system with my guest
Dr. Michal Rose.16:28 into mp3 file 
http://www.yalecancercenter.org/podcast/apr0410-cancer-answers-rose.mp3Foss
 Welcome back to Yale Cancer Center Answers.  This is Dr.
Francine Foss and Dr. Michal Rose joins me today to discuss cancer
care services at the West Haven VA.  Michal, we talked a
little bit about some of the services that were available, but I
want to get back to the point you made earlier which is that you
were actually cited and received a national award for outstanding
achievement in 2008.  Could you enlighten us a little bit
about what that award is all about?Rose
 Certainly Francine, thank you.  What I mentioned earlier was
an award that our VA as a facility received in general medical
care, so this is actually a second award.  This award was
specific for cancer care and it was granted by the American College
of Surgeons and it is called the Outstanding Achievement Award and
we received it last year for our work, for our survey I should say,
in 2008.  What happens is the College of Surgeons sets
standards regarding cancer staging, the use of tumor boards,
participation in clinical trials, community outreach, patient
education, and the functioning of a cancer committee in the
hospital and because we met all the standards with commendation, we
received this award and that really is a testimony to the fantastic
work by all the providers involved in cancer care at VA
Connecticut.  It really is a good team of devoted people.Foss
 It certainly does show the integration across a lot of different
disciplines coming together to optimize care for these patients and
we want to commend you on that award.Rose
 Thank you.Foss
 Can you talk a little bit about how you have seen the cancer
services expanding over the last couple of years as you have
grown?Rose
 Like all cancer centers in the country, we have expanded
enormously since I have been here and our numbers have gone up
increasingly and that reflects the fact that we have much more
effective treatment now for cancer.  Cancer patients are
living longer and we are able to help more patients than
before.  We have successfully incorporated all the new
chemotherapy agents into our practice.  One of the things that
we did last year, which I think was a huge step in the right
direction, was transitioning to using an automated electronic
chemotherapy ordering program, and that has really improved the
safety and efficiency of our work and, as I mentioned, our cancer
surgery program which is so specialized and high quality.Foss
 There are a number of new cancer drugs that are becoming available
every year and it is difficult sometimes to integrate these drugs
into an existing system.  Have you been able to access most of
these new drugs for your patients?19:36 into mp3 file 
http://www.yalecancercenter.org/podcast/apr0410-cancer-answers-rose.mp3Rose
 Yes, absolutely, we are very fortunate in the sense that we really
do not have to deny our patients any drug that has clearly shown
benefit for a cancer condition, and that is one of the things that
I really like about the VA, that I do not have to fight with
insurance companies.  My patients have pretty much full
benefits including medication benefits whether they are oral or
given via IV, and we have a very effective system working with the
pharmacy, our chemotherapy nursing, and of course oncology, to
integrate new agents smoothly into our practice.Foss
 In fact, I can say from my personal experience with a number of
patients that their outpatient prescriptions, some of which are
chemotherapy drugs, actually come through the VA system even though
they may be getting the rest of their care outside the system, so I
think the system works in a number of ways for a lot of people.Rose
 Yes, I agree.Foss
 You mentioned clinical trials and access to cutting edge
research.  Can you talk a little bit about how that is
integrated in the cancer center at the VA?Rose
 Research is one of the stated missions of the VA and, in fact, if
you look at cancer care in the United States there certainly have
been some pivotal trials that have changed the practice that
originated within the VA system and we offer our veterans an array
of clinical trials, some are VA based, some are through the VA
cooperatives studies group, some are part of national research
networks, and some are based at the VA and are initiated by
investigators at the VA.  We also refer our patients out for
clinical trials if we feel that they would benefit and the VA will
even pay for this sometimes when it is clear that standard of care
is sub-optimal for the cancer that they are suffering from.Foss
 You talked a little bit at the beginning in terms of your award
about integration with surgery and other services to optimize
care.  Do you have combined modality approaches for your
cancer patients and do you have clinical trials that involve
multiple different services?
  Rose
 Yes, definitely. For example, in prostate cancer we have a trial
that is actually run by our urology service and it looks at giving
chemotherapy either before or after surgery for prostate
cancer.  You really cannot practice oncology these days
without a multi disciplinary approach.  You have to be working
very closely with your surgeons, with your radiation therapist, and
for that matter with your social worker, dietician, and hospice
provider. I really do believe that patients benefit from that kind
of system.22:44 into mp3 file 
http://www.yalecancercenter.org/podcast/apr0410-cancer-answers-rose.mp3Foss 
            
 Michal, that leads me into my next question, which is what other
support services are available at the VA?Rose
 The VA has a fantastic system of support for its patients; our
social workers are the best.  They help with travel, we have
shuttles available for our veterans, and we even have hotel rooms
in the building in West Haven where patients can stay with their
spouses or significant others if they live far away and need to get
care in our facility.  Our veterans with mental illness have
very great support services to help them cope with their medical
illness.  It is exceedingly rare that a veteran does not get
care at VA Connecticut because of social or economic reasons and
that is really one of the reasons I like working at the VA.  I
really feel there is a great support system.Foss
 In terms of outreach back to the families as veterans are going
through cancer treatment,  what services are available say for
families and for counseling in that situation?Rose
 We have different types of mental health services that will work
also with the families and then we have a very active hospice team
that will work with the patient and the family.  In fact, this
was part of a national initiative that was launched in 2003 with
the goal of making hospice services available to all veterans with
incurable cancer and we really have a wonderful hospice
service.  They work with us side by side.  They visit the
patient in the hospital; they visit them in the clinic.  We
have an inpatient hospice unit if needed and one of the things that
our hospice team has been part of is what they call a Hospice
Veterans Partnership of Connecticut which was established to ensure
that all veterans have access to high quality end-of-life care and
that providers are educated regarding the special needs of
veterans, for example, we know that people suffering from post
traumatic stress disorder will often experience worsening of flash
backs when suffering from incurable cancer, and the goal of this
partnership is to make sure that the providers, the nurse who comes
to the home, wherever this provider will be, they are aware that
the patient is a veteran, and if they have a diagnoses, that the
provider will be aware of this diagnoses and know how to manage
them or at least know where to get advice if needed.  That has
been a very important initiative in Connecticut and nationwide.Foss
 Michal, I know there is always a little bit of confusion in
people's mind about the word hospice and most people think about it
as only end-of-life care, but it actually extends far beyond that
in terms of supporting folks through their treatment as well.Rose
 I agree, and I think that there is a general understanding that
the earlier you involve a palliative care hospice team in the care
of your patient with incurable cancer the better, and it does not
matter if the patient has several years to live, they are still
coping with cancer. We26:21 into mp3 file 
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 have a doctor and a nurse practitioner team, they are wonderful
people and they really help us take care of the patient, and if the
patient passes away, they also have a Bereavement Program that
extends for a whole year in which they send letters and offer
counseling services, so it is very very important.  We also
have a memorial service for our veterans several times a year in
which families can come and their loved ones are remembered in a
military-style ceremony.  We do it at VA Connecticut.Foss
 Sounds like there is a tremendous amount of support available
there for the family.Rose
 Yes, and I think our veterans really feel that this is their
second home and they will hang out in the VA maybe at the
cafeteria, they will speak to each other, they get a huge amount of
support just from talking to each other.  They really want to
know that this system is for them and they deserve it.Foss
 You have a couple of unique features to your system and I
understand one of those is a Cancer Care Coordinator.  Can you
talk a little bit about the role of that individual?Rose
 Yes, actually we have had a cancer care coordinator since January
2007, and this person helps patients navigate through this complex
process of cancer diagnoses, staging, and initiating care, and we
have shown an amazing improvement in our process since we hired
Laura Honeywell.  We know for a fact that our cancer patients
are being cared for in a much more timely fashion.  They get
their biopsies and scans done quicker, they are able to start
treatment faster and communication has improved, so the process is
much less stressful for the patients and their families and as a
result, in 2009, we found that we had increased our percent of
stage I and II lung cancers, so we are diagnosing cancer early
because we have such an effective system of coordinating
care.  I am very exited about this.Foss
 How can a patient access all this information that we talked about
today, is there a website for the VA?Rose
 The VA nationally has a very extensive website.  They also
have a program called My HealtheVet, which is a program in which
veterans can actually set up their own personal electronic medical
record and transport it to different VAs and to other facilities,
so that is a big thing.  VA Connecticut also has a website
that is not very extensive, and actually one of my goals is to
expand that website and expand our cancer center website so that
people will know more about what we are doing.Foss
 Michal, in the last minute, can you just tell us what your plans
are for the future of the center?29:42 into mp3 file 
http://www.yalecancercenter.org/podcast/apr0410-cancer-answers-rose.mp3Rose
 Certainly, my short term goal is to move to our new space. 
We are scheduled to move to a larger and nicer clinic and
chemotherapy infusion and office area and this one is going to be
on the fifth floor and the infusion room is beautiful with big
windows and a nice view and I really think that it will be much
more pleasant for patients and staff alike.  I would like to
expand our clinical trials program and I also want to create this
website and those are my short terms plans.Foss
 Sounds very ambitious.  Michal, I think I speak for everybody
in the country when I thank you for all of the work that you are
doing for our men and women that are serving in the armed forces
and the veterans as well, and it was really a pleasure to have you
here today to talk about the health care within the VA System here
in Connecticut.  This has been a terrific show and has given
us a wonderful overview of your work.  Until next week, this
is Dr. Francine Foss from Yale Cancer Center wishing you a safe and
happy week.If you have questions or would like to share your comments,
visit yalecancercenter.org where you can also subscribe to our
podcast and find written transcripts of past programs.  I am
Bruce Barber and you are listening to the WNPR Health Forum on the
Connecticut Public Broadcasting Network.