Dr. Michal Rose, Cancer Care for Veterans
April 4, 2010

Welcome 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 were

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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 rectal

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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 Yale

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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.

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Foss
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.

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Foss
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?

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Rose
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.

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Foss              
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. We

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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?

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Rose
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.