Welcome to Yale Cancer Center Answers with Dr. Francine Foss and Dr. Lynn Wilson.  Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas.  Dr. Wilson is a Professor of Therapeutic Radiology and an expert in the use of radiation to treat lung cancers and cutaneous lymphomas.  If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC.  This week we welcome Dr. Michal Rose, the Director of the West Haven VA Cancer Center.  Here is Lynn Wilson.


Wilson            Let’s start off by having you tell us a little bit about the West Haven VA Cancer Center and how it actually got started?


Rose              We have been around for a while now and we offer almost all services available for patients with cancer at the Veterans Affairs Cancer Center in West Haven.  We have all the specialties of surgery, neurosurgery for brain tumors, we have ear, nose, and throat surgeons for tumors of the head and neck area, we have dedicated thoracic surgeons, and we have gastrointestinal surgeons including liver, pancreas, and esophagus.  We also have, of course, a lot of urologists doing urology surgery.  We offer almost all types of chemotherapy and biological therapy.  The one thing we do not offer, as you know, is a radiation therapy.  We do not have a radiation therapy facility.  Most of our patients go to Yale Cancer Center at Smilow to get their radiation.  They get excellent care there.  So, pretty much, we are almost a full service cancer center.


Wilson            And of course you being a medical oncologist yourself are at the VA and so it really sounds like a multidisciplinary service provider for veterans, which is fantastic.


Rose              Yes, modern oncology and cancer care has to be multidisciplinary and we emphasize that at the VA and we work collaboratively with all our colleagues, so it works out pretty well.


Wilson            Who is eligible to come and be seen at the VA? Is it any veteran with a diagnosis of cancer or is suspected of having cancer, do they need to live in Connecticut?  What are background rules?


Rose              We take care of all the Connecticut veterans who have cancer.  We also take care of veterans from some other states.  We take care of veterans from Western Massachusetts, the Springfield area they can choose to go either to Boston or to West Haven, Connecticut.  They usually prefer to come to us, as we are little more accessible to them.  We also have some veterans that come from Rhode Island and from Albany for specialized care, but the vast majority of our patients are from Connecticut.


Wilson            But it sounds with that sort of reach that there are patients coming from pretty far away places.  If that is the case, say if someone is coming from Albany to see you and your team, for example, is it set up such that they can actually stay at the VA Hospital during their cancer care, what would be the logistics of something like that?


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Rose              That is a challenge for us because some of our patients do come from far away.  Fortunately, the VA has a lot of support for these veterans and these issues.  There are shuttle buses that run between North Hampton, Massachusetts, Springfield, West Haven, Newington, Bridgeport, and there are places that veterans can stay in West Haven or nearby free of charge, so that helps them.  We also have a little threshold to admit people to the hospital to help them get through workup or treatment for the ones that the travel is a hardship for.  We have a long-term care unit where veterans can stay for a few months when they are getting treatments such as chemotherapy and radiation, which helps a lot of older people get through the treatment.  So, although we face a challenge of treating people from far away, we have a lot of support for them.


Wilson            It sounds like all the bases are covered with all of those options, so that really does not sound like it would be a barrier for anybody who is interested or who will be coming for these services.  How long have you been involved with the West Haven VA Cancer Center? How did you get interested in this?


Rose              I have been a part of the VA Connecticut Health Care System, as it’s called, since 1999, so it has been more than 12 years now.  I have been the Cancer Center Director since 2005, and I did my training at Yale.  I did my residency there and my fellowship, and as you know the VA is an important affiliate of the Yale Training Programs, I spent a lot of time during my training at the VA and that is really when I became interested in working there.  Fortunately, when I graduated there was a position available and I have been there ever since.  There are lots of thing that attracted me to work at the VA.  I think first and foremost, it was the opportunity to take care of veterans.  I truly think they are the most deserving and appreciative people that I have ever worked with.  I like the fact that they also have comprehensive coverage.  We do not have to worry much about co-pays and coverage for medications and that makes our life much easier.  As you know, some of the cancer treatments are very expensive and the VA takes the approach that if it is FDA approved for the indications, and often even when it is not FDA approved for that indication but there is good data to suggest that the drug works, they will cover it even if it is expensive and that is a huge plus for our veterans and that was one of the things I liked about the VA, that I do not have to worry about the patients not having access to treatment that helps them.  I also love teaching and since all the Yale students, medical students, PA students, nursing students, resident fellows come through the VA, it is really a huge opportunity to make a difference and teach.  And last but not least, I wanted to be a part of Yale Cancer Center.  So, for me the VA job was really a perfect fit at the time and I still like it.


Wilson            What is your specific area of clinical expertise aside from your rather substantial amount of administrative work that you have to do making sure everything works well at the VA?


Rose              You could say I specialize in cancers that we see at the VA and cancers that veterans have.  I think my main interest always was the hematologic or the cancers of the blood and lymphatic system, but because we are relatively small, we are four full time oncologists, we all pretty much do


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everything, but like I said, we do not see all cancers at the VA, for example, since most of our patients are men, we do not see a lot of breast cancer and breast cancer is of course a very common cancer, the most common cancer in women, and we see very little of that.  So, I am probably not an expert in breast cancer.


Wilson            The changes that have happened at the VA since you have been there, and you have been there a long time now, what sort of things have you seen change that has been very positive for veterans?


Rose              Over this period of more than 12 years now, there has been a lot of very positive change, I have to say, the cancer center and the medical center as a whole have expanded enormously.  We now have more doctors than when I started, and we have more nurse practitioners.  We have more nurses working in our clinic.  We have more specialized surgeons.  We have surgeons who specialize in pretty much every type of surgery working at the VA.  We also have state-of –the-art equipment and we’ve always had a CAT scanner, but now we have several CAT scanners including state-of –the- art rapid ones, we have MRI machines, and we have PET scanners.  So, we have certainly seen changes in progress there.  When I started we only had clinic twice a week, we are much busier now, as we offer clinic everyday for patients.  One of the big improvements is the electronic medical record, the VA has always been a leader in the electronic medical record, and the rest of the community is really catching up with the VA now, but even within the VA there has been a huge development in this system.  One of the really exciting developments is that we now offer veterans access to their electronic medical record, so they can log in from a home computer and refill medications, schedule appointments, and they can also communicate with their clinicians through this secured emailing system.  It is making us more efficient and it is making us more patient centered and the patients, especially the younger generation of patients, really like it, so there has really been a lot of progress over time and I think we have improved a lot.


Wilson            That is very impressive, especially these improvements in efficiency for patients, and access to the system and to the doctors, which is really fantastic.  I am sure there are many civilian organizations that would love to have something like that, but it is obviously very labor and financially expensive to do so.  I know the VA has had a great system for a long time.


Rose              One of the other aspects is that all the VAs are connected through one electronic system, so if I have a veteran who goes to Florida for the winter, for example, I can, with a click of the mouse see what happened in Florida, at the Tampa VA, and that is true through the whole country and Puerto Rico, Hawaii, and Alaska.


Wilson            Wow.


Rose              It really makes it easier, also for veterans who transfer their care or have care in several sites.


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Wilson            Obviously you have many cancer specialists at the VA that you have listed and there are many many more.  Are all of these physicians also a part of Yale or do some work exclusively at the VA, or both places?  What is the relationship, are they affiliated with the medical school?


Rose              All our oncologists have academic appointments at Yale.  They all do teaching and research and that is true for most of the specialists that work at the VA.  It is also true for a good percent of the other doctors that work at the VA, primary care doctors and others, so I think that is really one of the strengths of the VA, is its affiliation with medical centers, specifically Yale in our case.  I think it makes for better doctors and better care.


Wilson            That is fantastic.  You have mentioned a little bit about some of the cancers that you do not see too much of at the VA and some others that you might see more commonly.  What is your sense of the main types of cancers that affect the veterans that you care for?


Rose              Still over 90% of our patients are men, but that is changing as more and more women are serving in the military but we still see mostly cancers that affect men.  Unfortunately a lot of our patients smoke or used to smoke, so we see a lot of smoking related cancer such as lung cancer, bladder cancer, and the other top sites common among the veterans are prostate cancer, of course, and we see quite a lot of malignant melanoma, which is really the most dangerous form of skin cancer.  Some of our patients are Vietnam veterans and they were exposed to Agent Orange, a pesticide that was used in Vietnam to exfoliate the trees, or make the leaves fall off the trees.  Exposure to Agent Orange is associated with several cancers, especially lymphomas and related conditions, leukemia. It is probably also associated with lung cancer and possibly prostate cancer, so that may explain part of the increased incidences of those cancers among Vietnam veterans.


Wilson            And most of those veterans, when you talk to them and take their history, are they usually pretty confident that they might have had Agent Orange exposure to help you sort the issues, or sometimes is it unclear?


Rose              I do not determine whether they were exposed or not, but I know that the VA has become more lenient in their criteria of deciding who was exposed to Agent Orange.  They used to require that the veterans were heavily exposed in the jungles.  Now they realize that even people who were in the bases or transporting Agent Orange probably had an exposure and sometimes the veterans did not know necessarily exactly what their exposure was and this has significance regarding compensation if they are disabled related to an Agent Orange condition.  That is not really something that we determine but there are a lot of people at the VA where that is their job, to determine their eligibility for compensation.


Wilson            We are going to take a short break for a medical minute.  Please stay tuned to learn more information about cancer services that are available at the West Haven VA Cancer Center with my guest Dr. Michal Rose.


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Minute            The American Cancer Society estimates that the lifetime risk of developing colorectal cancer is about 1 in 20 and that risk is slightly lower in women than in men.  Early detection is the key. When detected early, colorectal cancer is easily treated and highly curable.  Men and women over the age of 50 should have regular colonoscopies to screen for this disease.  Each day more patients are surviving the disease due to increased access to advanced therapies and specialized care.  New treatment options and surgical techniques are giving colorectal cancer survivors more hope than they ever had before.  Clinical trials are currently underway at federally designated comprehensive cancer centers like the one at Yale to test innovative new treatments for colorectal cancer.  New options included Chinese Herbal Medicine being used in combination with chemotherapy to reduce side effects of treatment and help cancers drugs work more effectively.  This has been a medial minute and more information is available at yalecancercenter.org.  You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.


Wilson            Welcome back to Yale Cancer Center Answers.  This is Dr. Lynn Wilson and Dr. Michal Rose joins me today to discuss cancer services at the West Haven VA.  We have talked in some detail about the VA and the types of physicians and types of patients that are cared for, but how do veterans access the system? If they are concerned that they may have a condition that is cancer, or perhaps their physician has suggested to them that that is the case, how do they actually get into the system, obviously if they are in the VA, already being cared for by a primary care physician at the VA that is pretty straight forward, but what if someone has not sought any medical care in quite sometime and feels a lump in their neck.  How do they get into the system?


Rose              It does vary, the VA does require that every veteran has a primary care provider and that is really a key to good care.  I do believe in that, so like you said, people who have a primary care provider do have access immediately to specialists when the need arises.  We do have veterans who have not been in the system for a while and will come to the emergency room with the new issue and we address it and depending on the urgency of the case we will see them, some get admitted for workup and some get urgent appointments in our clinic.  We really have open access in our clinic and the VA has also put together guidelines on how quickly patients should be seen which has helped.  We always triage our patients and see them as soon as we can, but we have to everyone within two weeks basically, and of course some are seen the next day, so it is a pretty good method of accessing our services.


Wilson            You mentioned some services that the VA does not offer, and that was an extremely limited list such as radiation, but you have methods set up for patients to get access to radiation therapy services at Yale, for example.  Are there are any other services that you have to send patients elsewhere for that may not be available in West Haven?


Rose              We do send some patients for these very specialized surgeries that need very sophisticated


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                     equipment, usually they get sent to Yale and we send patients for clinical trials that are not available in our VA.  And also women with gynecological cancers because we see so few of them, they all go outside the VA for treatment usually again to Yale which has an excellent program for gynecologic cancers.  But we can take care of the majority of the veteran’s needs within the system and usually the veterans prefer that because they appreciate the ease with which they can access the care and the fact that the care is coordinated.


Wilson            If someone needs to have a specialized service say at Yale, for example, generally is the VA helpful in having those costs covered since obviously that care may be outside the formal VA system? How would that work for a patient generally?


Rose              It usually starts with us, with the doctors, so if we recognize there is a good treatment for the patient that we cannot offer, there is a procedure that we can initiate to get the care approved and it is actually streamlined, so it is all electronic, we put in an electronic consult that goes to the administration and they have a physician review it and sometimes they will ask us some questions, but in most cases it is quite simple because it is clear cut the services that we cannot offer.  Because oncology changes and progresses all the time, we do have to sometimes advocate for patients and fight for them to get treatments that we think could help them that may be expensive and we could not offer, but really have a good chance of helping them, but overall I found our administration to be very very supportive of the needs of the veterans with cancers and am very much aware of the fact that treating cancer is a moving target and there will be new options out there that we could not offer and that the patients deserve.  So, I have not found big barriers for our patients.


Wilson            I have been asked about this before, say we have a patient who is a veteran, but for whatever reason has sought their healthcare for last 20 years in the non-veteran or rather civilian system and say they have Medicare, for example, but perhaps they have been diagnosed with cancer and they would like a second opinion about this.  Are they eligible to come to the VA for assistance in that situation?


Rose              Yes, most veterans are eligible to come to the VA.  There are variations in co-pay.  So people who are relatively well off and have a regular income, will have a co-pay at the VA and sometimes it is cheaper for them actually to get care outside the VA.  The medication benefit is usually good at the VA, so the co-pay for medication is usually much less than the patient would pay on the outside especially for the expensive oncologic treatments and so that often is a reason that draws patients to the VA.


Wilson            What are some of supportive care services available to patients at the VA?


Rose              We have great supportive services actually, we have very dedicated social workers, care coordinators, and a psychologist.  We have a palliative care team and a hospice team that support


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                     veterans in their homes and provide inpatient hospice care if needed.  We have this fantastic program in which veterans are actually trained to help and take of other veterans with cancer and they go to their houses, especially for veterans that live in rural areas, and help them out and that is one of the wonderful things at the VA, this camaraderie between the veterans.  It is really amazing; they are always helping each other.  They are also making friends in the waiting room.  Also, many of the people who work at the VA are veterans and I think that really makes a big difference.  You can see the dedication.  They were there themselves and so really the supportive care services are remarkable.


Wilson            Are there hospice options for patients?  Is there something formerly through the VA or do you have to rely on systems outside the VA for hospice care?


Rose              No, the VA has its own inpatient hospice at West Haven, which is usually our patients’ first choice if faced with that situation, because they feel it is their own place.  The VA will also pay for patients to go to other facilities near their homes for veterans who live a little bit of a distance from West Haven and they will also pay for them to have home hospice services, so the VA is actually very supportive of hospice services and there is a national directive that comes from the central office that mandates that all veterans with incurable cancers have access to hospice care early on in their disease and the other advantages are there are really no limitations on this hospice care, so I can have our hospice team see a patient with lung cancer, although I may still be treating this patient and giving them chemotherapy and this person may not be what we call terminal.  They still benefit from a discussion with the hospice team to find out what their options are and what to expect down the line.  So it really enables us to have the hospice services involved early on, which I think our patients really appreciate.


Wilson            What services do you offer at the VA that may not be offered at other institutions, other veterans affairs hospitals?


Rose              Our VA has actually taken the lead in several aspects of cancer care and we are very proud of that.  We were the first VA in the nation to offer comprehensive cancer care coordination services.  We hired our first dedicated cancer care coordinator in 2007, and we now have two other nurses serving in that role, so we have three coordinators.  Our coordinators are alerted electronically immediately to all new cases of cancers, they expedite the care, they serve as a point of contact for the veterans and their families as they go through the diagnostic process and the staging process, which as you know is a very scary process, and they always have a phone number to call and find out what is going on, what appointments are coming up, why and what is the reason for the workup.  We have seen huge benefits to patients with this program.  We have seen that the timeliness of care is improved.  It takes patient’s less time to start their treatment, so there is less anxiety and much less suffering and actually many VAs in the country have followed our model.  They have consulted with us as they build their own navigation program so that has been a success and we are proud of it and there are a lot of other things I can talk about we were one of the first in


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                     the country among the VAs to offer robotic surgery for prostate cancer, and we now offer other robotic surgeries for head and neck surgeries, for lung surgeries.  We were one of the first to offer multidisciplinary liver cancer service. The incidence of liver cancer is rising nationwide and in the VA and it really is a cancer that requires multidisciplinary care and we have a very active program.  We are one of the few that organize a cancer survivor’s day every year, and I can give you lots of examples but really we are always looking for ways to improve and I am very fortunate because I work with a wonderful group of people that are dedicated to the cause of improving cancer care for veterans and I think our veterans really benefit from it.


Wilson            Tell us a little bit about screening options for patients?  What if someone may not have overt symptoms but may just be worried that they could be at risk for cancer?  Are there screening options for these folks?


Rose              The VA is a leader in cancer screening and preventive care.  In fact, studies have shown that veterans are screened for cancer at a higher rate than other populations.  The VA has placed a huge emphasis on primary care and preventive help.  That was really a major part of the VA system reorganization that happened in the 1990s under the direction of Kenneth Kaiser.  He was then the VA undersecretary of health and the VA is really now a model for a system that provides quality care.  Recently, there were a couple of studies showing that the quality of cancer care is at least as good if not better than the average care Medicare patients get.  One study that was published last year showed that veterans were diagnosed with earlier stage colon cancer than in the community.  They are at higher rates of surgery for the colon cancer and they are at higher rates of appropriate treatment for lymphoma and for myeloma, so like I said, the VA system as a whole has been a model for quality care and I am proud to work there.


Wilson            I can see that Michal.  What are your plans for the future?  Are there any plans for expansion of this center?


Rose       Yes, actually we are moving to a new space this year, and we are very excited, it should be in a few months.  It will enable us to offer our patients treatment in a more comfortable environment, a larger infusion area, and more exam rooms.  We hope to offer patients and their families’ access to some complimentary activities, also such as art therapy, yoga, massage, and relaxation techniques.  We also plan to open more clinical trials.  These are exciting times for oncology and we need to move with the times so that our veterans will get the best care.


Dr. Michal Rose is Director of the West Haven VA Cancer Center.  If you have questions or would like to add your comments, visit yalecancercenter.org, where you can also get the podcast and find written transcripts of past programs. You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.