Dr. Michal Rose, Cancer Services for Veterans
February 8, 2009

Welcome 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 our

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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 and

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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?

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Rose             
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?

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Rose
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, integrated

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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 their

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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 an

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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.

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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.