Cancer Answers: Cancer Services for Veterans, February 8, 2009

Dr. Michal Rose, Cancer Services for Veterans February 8, 2009Welcome to Yale Cancer Center Answers with Dr. Ed Chu and
Dr. Ken Miller, I am Bruce Barber.  Dr. Chu is Deputy Director
and Chief of Medical Oncology at Yale Cancer Center and an
internationally recognized expert on colorectal cancer.  Dr.
Miller is the Director of the Connecticut Challenge Survivorship
Program and he is also the author of "Choices in Breast Cancer
Treatment."  If you would like to join the discussion you can
contact the doctors directly at canceranswers@yale.edu and the
phone number is 1888-234-4YCC.  This evening Ed is joined by
Dr. Michal Rose, Director of the West Haven VA Cancer Center. 
Dr. Rose is also an Associate Professor of Medicine at the Yale
University School of Medicine.Chu
 Many people may not be aware of the types of cancer services that
are available at the VA Medical Center.  Can you tell us a
little bit about the West Haven Cancer Center and the types of
cancer services that are available for patients?Rose
           
 We are located in West Haven on Campbell Avenue.  Right now,
we are the only inpatient facility in the State of Connecticut. As
many people know there used to be an inpatient facility in
Newington, Connecticut but that was closed down as an inpatient
facility, and remains an outpatient clinic, so we are the only
hospital in Connecticut right now.Chu
 As I understand it, you have done a terrific job since you have
taken over the cancer service and you also provide the cancer
services for the Newington area, is that correct?Rose
 Correct.  We provide cancer care for all enrolled veterans in
Connecticut, and veterans also come to us from Western
Massachusetts and sometimes even parts of New York.Chu
 What are the types of patients that can be seen at your
facility?Rose
 We offer pretty much all forms of cancer care. We have excellent
surgeons, general oncologic surgeons, cardiothoracic surgeons who
do lung surgery, ear, nose, and throat surgeons, and neurosurgeons,
so from the point of view of surgery we are pretty much covered and
we do all the medical oncology care.  The facility that we do
not have is radiation therapy, and we send most of our patients to
the Yale Therapeutic Radiology Department where they provide us
excellent care. They come to our tumor boards and they have access
to our patient's records directly electronically, so that works
very well too.Chu
 How long have you been at the West Haven VA?Rose
 I have been there since 1999; almost 10 years.  Our program
has grown significantly over that time, mostly because of the aging
of the veteran population and the fact that our3:04 into mp3 file 
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 patients with cancer are surviving longer.  We had to expand
our program over this period in order to continue to provide
quality care and keep up with all the exciting developments in
cancer treatment.  One of the changes I want to mention,
because I am especially proud of it, is the hiring of a Cancer Care
Coordinator.  This is a person who helps expedite the care of
patients newly diagnosed with cancer and guides them through the
complex process of tests and staging and offers them and their
families' emotional support during that period.  Since our
nurse practitioner, Laura Honeywell, was hired into this new
position, we have been able to show a significant reduction in the
time it takes to get patients with newly diagnosed cancer into
treatment.Chu
 That is terrific. As the services have expanded and we are able to
offer our patients more complicated multidisciplinary approaches,
it is really critical to have such a coordinator to help these
patients navigate through the whole process.Rose
 This kind of navigator has become more popular, and I know other
hospitals are starting to hire them, but we are one of the first
VA's in the country that has appreciated the need and hired such a
person.Chu
 One of the nice things is that you also have a dedicated
outpatient clinic, and a dedicated chemotherapy infusion center
that is separate from the rest of the hospital facility, which I
think helps in terms of providing the type of care that we would
like to offer to our cancer patients.Rose
 That is exactly right.  We have a pretty good setup with our
chemotherapy infusion room right next to our clinic space and the
pharmacy right nearby.  We hope to improve on that
significantly this year because we are supposed to be moving to a
new space that is larger and has a larger infusion room, which we
sorely need because of the increase in our services. That space has
already been allocated to us and is undergoing renovation now, so I
hope to move in this year which will be a huge benefit to our
patients. It is a much more aesthetic surrounding, and provides
more flexibility in scheduling; I am very excited about that.Chu
 That is terrific.  Do you primarily see patients, veteran
patients, who reside in the State of Connecticut or do you also see
veterans referred from other parts of the Northeast Region?Rose
 We see veterans mostly from Connecticut but also from Western
Massachusetts, North Hampton. The VA is very good about helping
veterans with transportation, for example, not only are there a lot
of shuttles that bring our veterans from parts of the state and6:08 into mp3 file 
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 Massachusetts, there are also rooms where the veterans can stay
free of charge in the building if they are undergoing several days
of testing. Sometimes they will stay there for a few weeks if they
are getting radiation therapy and chemotherapy at the same time,
and like I said, those rooms are offered to them free of charge and
they are nice rooms so that is a huge help to our veterans, many of
which live far away and do not have many resources or support.Chu
 If a patient is diagnosed with cancer and comes to you for say,
chemotherapy, does that individual have to pay anything or is that
completely covered because they are a veteran and the government
helps provide the resources for their care?Rose
 That is actually a pretty complicated question and I am not sure I
can answer that fully, but I will tell you what I know. 
Veterans are classified into priority groups, and their eligibility
and co-pays depend on their income and their priority groups. 
For example, veterans who are determined to have a significant
disability related to their military service will get care for
free. Vietnam Veterans exposed to Agent Orange that develop a
cancer related to this exposure, mainly prostate cancer, lung
cancer, or lymphoma, are also eligible for high priority care. And
our newest veterans, those returning from "Operation Enduring
Freedom" and "Operation Iraqi Freedom," are eligible to receive
high priority care for 5 years.  So, the co-pays are
individualized depending on your service connection, your income,
and many other factors.Chu
 Terrific.  What resources are available for patients who
might be in need of say surgery for their particular type of cancer
or radiation therapy?Rose
 As I said earlier, pretty much all types of cancer surgery are
offered at VA in West Haven; general oncologic surgery and urologic
surgery.  We even purchased the da Vinci Robot for prostate
cancer surgery; one of the few VA's in the country.  We do
neurosurgery, and in fact, we get referrals from various areas in
New England for neurosurgery, and we do lung surgery.  We do
not have a radiation therapy facility, and we refer these patients
to the Yale Therapeutic Radiology Department.  Some veterans
are referred to radiation therapy facilities near to their home in
the Hartford area or Massachusetts, but the ones receiving combined
treatment, chemotherapy and radiation, and sometimes surgery, we
try to keep all their care coordinated in one center in West Haven
and we will use the Yale facility which, like I said, has been
working very well with the VA and gives our veterans excellent
care.Chu
 How can veterans who are living here in the State of Connecticut
access the various cancer services that your program provides?9:27 into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-08-09.mp3Rose  
          
 They usually are referred to the oncology service through their
primary care doctors, and once they have their appointment with us,
we make the referral to Yale if they need radiation, and we
coordinate with the surgeons.  We have a lot of prostate
cancer cases in the VA, and if it is early stage prostate cancer
the patients will go to the urology service. They have a very
active tumor board in which they meet with us, with the
pathologist, and the radiologist, to go over all the data and make
a plan of treatment and then proceed from there.  It works
pretty well.Chu
 Can you briefly review the main types of cancers that are seen at
the VA Hospital?Rose
 Just to give an idea of the numbers, in 2007 we diagnosed 518 new
patients with cancer.  Our population is predominately male,
although that is changing and we are getting more women
veterans.  The most common cancers we diagnose are prostate
cancer, bladder, lung, colorectal, and malignant melanoma, but we
do see everything.  We see pretty much all cancers and take
care of them at VA Connecticut.  There are only a few fields
in which we feel we do not have the expertise to do it ourselves,
and that is mostly the gynecologic cancers. We will refer that
veteran to a center that specializes in that, usually Yale.Chu
 If an individual should need care that may not be available at the
VA, what do you typically do?Rose
 Our veterans are entitled to all the care that is appropriate for
their condition, and if we cannot offer the service, which does not
happen often, we have a pretty streamlined process of referring
them elsewhere, like we will do with the gynecological cancers. We
will also do that for some other services such as genetic
counseling when indicated. We usually use the Yale Genetic
Counseling Service and Radiation Therapy, most of the rest we will
do inhouse.  There are other resources for veterans that we
encourage them to use; The National Cancer Institute will offer
free cancer care to people who qualify for their clinical
trials.  Some of our patients with rare cancers will be
referred there. We offer some clinical trials at the VA, and we
encourage our veterans to go to Yale for clinical trials. 
Some of the Yale trials are open at the VA, and we have our own VA
specific clinical trials. When we have a patient who we feel would
be best served by a clinical trial, we will get in touch with the
appropriate investigator at Yale and make that referral.Chu
 Maybe we can talk a little bit more about the types of clinical
research that are ongoing at the VA.  One last question before
we take a break, if a patient is referred outside of the VA system,
are those services covered by the VA system?13:30 into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_Feb-08-09.mp3Rose
 Yes, if we as oncologists feel that this care is appropriate, the
VA will cover it. The veteran may have the same co-pays he or she
has at the VA, but the rest will be covered. The VA actually has a
pretty good billing system that takes care of that.Chu
 You are listening to Yale Cancer Center Answers and we are here
discussing cancer services at the West Haven VA with our guest
expert this evening, Dr. Michal Rose.Chu
 Welcome back to Yale Cancer Center Answers, this is Dr. Ed Chu and
I am here in the studio this evening with Dr. Michal Rose, Director
of the West Haven VA Cancer Center. Before the break we were
talking about the various cancer services and the various programs
that are provided at the West Haven VA Cancer Hospital. One thing I
failed to ask you Michal is, what do you view as your own area of
speciality expertise with respect to taking care of cancer
patients?Rose
 Thank you Ed.  Before I get to my own specific interest I
just wanted to say a little bit about how I see the VA system and
why I am there. Like I said, I have been there almost 10 years now,
and I would like the listeners to know that over the past 10 years
the VA has really transformed itself from a system that was
somewhat controversial, to one that is now nationally renowned for
providing quality care at a significantly lower cost than the
nation's average.  Especially in times like this, there is a
lot of appreciation for the fact that medical care can be given at
a high quality with a cheaper cost, and there have been several
studies published that have shown that the VA is performing even
better than Medicare and other healthcare systems on multiple
performance measures, which include preventive medicine and the
management of chronic illness. This transformation at the VA
occurred through national reorganization that I am sure many of our
listeners have heard of.  There was a shift from hospital
based to outpatient based care, there is a strong emphasis on
primary care, there is a mandatory use of an excellent,
integrated16:34 into mp3 file 
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 electronic medical record, and there is extensive use of quality
measurements.  I have been involved on my side over the past
few years in several national initiatives to measure and improve
cancer care within the VA system, and the VA is especially suitable
to these types of initiatives.  The veterans are enrolled in
the system for life, making investment in processes that improve
care worthwhile and there is a culture of quality measurement, and
I feel that by being involved in these initiatives, I can impact
not only the care of our veterans in the area in Connecticut, but
maybe a little on the national level.Chu
 When I was at the VA Hospital working closely with you, one of the
things I noticed was the wonderful electronic medical record that
allows for seamless communication between the inpatient, outpatient
setting, and between all of the various doctors who are taking care
of a particular patient. You can really know, just with a click of
the mouse, what is going on with your patient at any step along the
way.Rose
 That is very true.  In fact, the system is the envy of most
other hospitals, and for anyone who has ever been a patient and
gone to their doctor and been faced with a situation where the
doctor did not get the report of the CAT scan or the blood test
that was done, it was lost in the mail or in the filing system, we
face none of that. With the click of a mouse, like you said, we can
get all the information we need.  We have the pharmacy records
right there, we know what medications the patient is on and when
they last filled their medication, we know what their most recent
CAT scan showed, their blood work, and we know what the consultant
said, because it is all there electronically, and that is wonderful
and contributes to the efficiency of the system.  The VA is
actually going one step forward on a topic that maybe some people
have heard about, it is called My HealtheVet, which is a kind of
internet based system where veterans are able to log into their own
medical records. The system was launched recently and is still
being developed so I am not really the expert on it, but veterans
are able to see their upcoming appointments, they are able to
request refills of medications, and they are starting to put
together a system where they can communicate with their physicians
and ask questions and get their answers electronically.  They
can also create their diagnosis list and their medication list in a
little wallet card that they can carry with them. The system has
endless possibilities, so that is just an example of the commitment
to the electronic age that we see at the VA.Chu
 It helps to empower the patient's rights; it makes them feel like
they are in control of what is happening with their healthcare.Rose
 Before the veterans come to visit, they can actually put
information there about their20:01 into mp3 file 
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 symptoms or tests they had from outside.  If they had a
colonoscopy privately, they can inform their provider
electronically and that becomes part of their record.Chu
 It is interesting, as we are having this pretty healthy and
vigorous debate about the role of government intervention
vis-à-vis this financial economic meltdown, obviously the
folks who are against it are saying the government is grossly
inefficient, but I think the VA Healthcare System is a very good
example of where the government actually can work to the benefit of
patients.Rose
 I totally agree, not to get into politics here, but the VA is an
example of a very successful government operation that a lot of the
private sectors could learn from.Chu
 We still have not gotten to your own particular area of
expertise.Rose
 I guess you could say I specialize in cancers that affect our
veteran population.  If I have an area of expertise, I would
say it is the blood, or hematologic malignancies, but at the VA we
are relatively small group, we are three full-time oncologists and
two part-time, so we all do everything.  We are fortunate to
also have the expertise of the Yale Cancer Center specialists, so
when we have a particularly difficult case we can always email or
pick up the phone and discuss the patient and their management, and
that is a huge advantage that helps us provide academic
state-of-the-art care.Chu
 You just mentioned Yale Cancer Center, can you describe a little
more about how your VA Connecticut Cancer Center and the Yale
Cancer Center and the Yale School of Medicine are linked?Rose
 We feel we are an integral part of the cancer center.  We all
have faculty appointments at Yale.  We play a huge role in the
education of our trainees, medical students, residents, and
fellows, they all rotate through the VA and we interact with them,
give lectures, and we are part of selection committees and
interview committees.  On the education part, we play a huge
role, and the other side to this is of course, the research side,
and there are ample opportunities for collaboration with Yale
researchers. We do that through lab work, clinical trials, and like
I said, some of the Yale trials are open at the VA and we refer
patients over to Yale for appropriate clinical trials.  We
also have some very exciting lab based research at the VA.  We
have labs working on new drugs for colon cancer and kidney cancer,
and we have some VA trials, so there are some cooperative groups
nationwide through the VA system that are studying different
approaches to treat common cancers that affect our VA population.
We have a couple of trials open for prostate cancer, and we also
have a myeloma trail open.  On one hand we are really an23:27 into mp3 file 
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 integral part of the Yale Cancer Center research effort, and we
also participate in VA initiatives and we have both advantages
there.Chu
 Maybe one thing that people may not really appreciate is how
tightly linked the faculty members at the VA and the Yale School of
Medicine really are. I do not know what the latest figures are, but
I know that for quite a long time the Yale West Haven VA, as we
like to call it, has always been viewed nationally as one of the
top two or three VA's in the country, because, I think, of its very
close relationship with the Yale School of Medicine and Yale Cancer
Center.Rose
 That is totally right.  If you look at rankings nationally,
the West Haven VA ranks very high in research money, and we have
some multiple centers of excellence, and I agree with you that a
lot of that is thanks to this strong affiliation we have with Yale
University Medical School.Chu
 Can you briefly highlight some of the supportive care services
that might be available to patients at the VA, because, as we are
getting more and more able to treat various cancer types,
maintaining quality of life is very important.Rose
 I would like to mention several services that have developed over
the last few years.  We have a support group for general
cancer patients, and one of the services that have developed over
the last few years that has been very successful is our palliative
care service.  We have a very wonderful team of palliative
care nurse practitioners and doctors that help coordinate care for
patients who are at the end of their life.  We have an
inpatient hospice that provides a smooth transition for patients
who are suffering from terminal cancer. This service has brought
huge comfort to our veterans with incurable cancer, and has been a
wonderful addition to our services over the last few years. 
It is part of a national movement within the VA system to provide
palliative care and offer it to every veteran diagnosed with
incurable cancer, no matter what the stage of their disease is.
Although as oncologists we have a lot to offer patients, we also
want them to know that we have the means to alleviate suffering and
provide that kind of support that you are asking about.Chu
 In the last 90 seconds or so, is there any last minute message
that you would like to send out to the veterans who might be
listening to this show?Rose
 It is my honor to serve the veterans.  We are here for our
veterans and I feel fortunate to be a part of an amazing team of
providers at all levels. At VA Connecticut we are here to help you,
please utilize our services. It is our honor to serve you.27:06 into mp3 file 
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 Chu I want to take this opportunity to commend you Michal,
and your team, for doing a terrific job in terms of providing
cancer services to veterans throughout the State of Connecticut and
throughout the regional New England area.Rose
 Thank you Ed, and thank Yale Cancer Center for all their support
because it is a combined group that excels.Chu
 It really is a team effort as Hillary Clinton says, "It Takes a
Village."  You have been listening to Yale Cancer Center
Answers and I would like to thank my guest this evening, Dr. Michal
Rose for joining me.  Until next time, I am Ed Chu from Yale
Cancer Center wishing you a safe and healthy week.If you have questions or would like to share your comments,
go to yalecancercenter.org, where you can also subscribe to our
podcast and find written transcripts of past programs.  I am
Bruce Barber and you listening to the WNPR Health Forum from
Connecticut Public Radio.