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TABLE OF CONTENTS

Cancer Committee Membership................................................................................. 1

Cancer Committee's Chair Report.............................................................................. 3

Tumor Registry Report.............................................................................................. 4

Tumor Board Report.................................................................................................. 4

Primary Site Table..................................................................................................... 5

5 Most Frequently Occurring Sites............................................................................. 6

Cancer Care & Support Services................................................................................ 7

A Veteran’s Cancer Journey by Richard Loubriel …………………………………. 24

Standard 4.7 and 4.8 Studies of Quality/Quality Improvements................................. 27

Association of VA Hematology/Oncology (AVAHO) poster presentations................ 30

Standard 4.6 Multiple Myeloma................................................................................... 32

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COMPREHENSIVE CANCER COMMITTEE

The Cancer Committee includes representatives of professional specialists as recommended by the American College of Surgeons Commission on Cancer with areas of responsibilities including: coordinating educational activities for nursing staff, students and professionals; coordinating multi-disciplinary treatment groups such as Oncology, Radiation Oncology and Hematology related clinics and Tumor Board; and overseeing the functioning of the Tumor Registry.

The Cancer Committee is responsible for discussing the diagnosis and treatment of patients with malignancy within the facility as well as reviewing the medical records of cancer patients.

2017 MEMBERSHIP

REQUIRED:E. Ball, CCRP Representative Clinical Research CoordinatorS. Bhatia, MD Representative Radiation Oncology K. France, RN Representative Radiation/Oncology Nurse T. Jardine Cancer Program AdministratorR. LaTourrette, MS, RD, CDN, CSO, CNSC Community Outreach Coordinator/Rep NutritionA. Lupinetti, MD Representative General Surgery/QM Coord.B. McCandless, MD Representative Diagnostic Imaging-Nuclear MedL. McCarthy, MD Representative Pathology/LaboratoryS. Mehdi, MD, FACP Cancer Conference Coordinator/ChairP. Minkler, RN Representative Hematology/Oncology NurseR. O’Malley, MD ACoS Liaison/General SurgeryD. Pasquale, MD Cancer Registry Quality Coordinator/Rep HemT. Thierbecker, LCSW, OSW-C  Representative Social WorkI. Uppal, MD Representative Pain Control/Palliative Care B. Williams, CTR Tumor Registry CTR

ALTERNATES:S. Casler, NP Representative Pain Control/Palliative CareT. Ferrario, MD ACoS Liaison/General SurgeryR. Grembocki Representative Clinical Research CoordinatorP. Hegener, MD Representative Diagnostic Imaging-Nuclear MedT. Kidder Representative Social WorkE. Kim, MD Representative Hematology/OncologyY. Lau, MD Representative Radiation OncologyM. Le, MD Representative General SurgeryT. Norris Representative NutritionR. Patel, MD Representative Pathology/LaboratoryV. Thalody, MD Representative Hematology/Oncology

AD HOC:R. Dyer, OT Representative Rehabilitation MedicineM. Herrington, RN Quality Improvement LiaisonD. Kupiak, R. Ph Representative PharmacyA. Payne, MD Representative PsychosocialC. Reyes-Lopez/H. Park, MD Representative DentalJ. Richter, SW Representative American Cancer SocietyM. Roth, MD/R. Grimm, MD Representative Primary Care

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STRATTON VA COMPREHENSIVE CANCER COMMITTEE MISSION STATEMENT

The Comprehensive Cancer Committee supervises activities related to cancer treatment, control, education and reporting within the Medical Center. The committee maintains and expands activities within our

community of Veterans to insure the broadest spectrum of quality care for patients.

The departmental reports data dates are January 1, 2017 thru December 31, 2017.

COMPREHENSIVE CANCER COMMITTEE CHAIRMAN’S REPORT

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According to the American Cancer Society (ACS), 1.7 million Americans will be diagnosed with cancer in 2018 and approximately 610,000 will die from it. ACS also states that despite a 25-year decline in cancer mortality rate, cancer is the second leading cause of death in the United States and will surpass cardiovascular disease to become the leading cause of death in the next decade.

During the last couple of years cancer is being redefined from traditional pathological diagnosis to include the genomic information for accurate diagnosis. This has evolved into Precision Medicine and significant improvement in overall survival. These are very challenging and exciting times.

Our cancer program has been accredited by the Commission on Cancer for over 56 years. The cancer committee is responsible for evaluating quality of care, quality improvements, cancer registry, research & outreach activities and continued educational activities by active participation in the multidisciplinary cancer conferences (Tumor Boards) and quarterly Comprehensive Cancer Committee meetings.

Our cancer program is comprised of a dedicated multi-specialty team which includes: Certified Tumor Registrar, Chaplin Services, Medical Oncology, Hematology, Radiation Oncology, Interventional Radiology, Surgical Oncology, Dental services, Speech Therapy, Palliative Care, Psychiatry, Nutrition, Quality Improvement, and Primary care.

Each year the members of the cancer committee set up goals / studies to improve the care provided to cancer patients. We brainstorm ideas in the beginning of the year, and then meet quarterly to follow up. In these meetings we discuss the progress of various goals and studies, their timeliness of completion, and trends in survival. At the end of the year, we share our annual report with the entire medical center and community at large.

Some of the goals, quality improvements, and individual department achievements are well outlined in this annual report and I do not want to steal the thunder by mentioning them here.

My report would be incomplete if I do not mention the hard work, devotion dedication of Bernice Williams CTR without whom our cancer program would not have survived. She is a visionary and indeed an asset to our facility.

In the end, I would like to thank all the members of the cancer committee for their tireless care, sincere and continued commitments to the fight against cancer. I am positive that with the current pace of scientific advancements and dedicated individuals like our cancer committee members, cure will no longer remain only a dream.

Syed Mehdi_Syed Mehdi, MD FACPChair Cancer Committee

2017 TUMOR REGISTRY REPORT

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Bernice Williams, CTR

The Tumor Registry at the VA Medical Center has a reference date of January 1955 (27,488 alive/dead patients) and currently utilizes a computerized/manual system. In addition to registering and following patients with a diagnosis of malignancy, the Registry provides data for research and education to staff. Our data is captured and submitted in accordance with the guidelines and procedures are set forth by the American College of Surgeons Commission on Cancer, the State of New York, the SEER (Surveillance, Epidemiology and End Results) of the National Cancer Institute (NCI), National Cancer Database (NCDB) and the VA Central Cancer Registry (VACCR). Interfacing with all the components that make up the Cancer Program, the data collected by the Registry helps promote quality patient care as well for present as well as future cancer patients. The registry is currently staffed by Bernice Williams, CTR.

The Stratton VAMC Cancer program is accredited by the Commission on Cancer (CoC) as a Veteran’s Administration Cancer Program (VACP). Our program’s compliance with the CoC standards is committed to providing the best in cancer diagnosis and treatment.

Lifetime follow-up of patients included in the database supports clinical follow-up & surveillance of additional primaries. Follow-up data includes neoplasm status (free or residual/progressive disease), recurrences, subsequent treatment, and vital status. The Tumor Registry maintains a follow up rate for patients diagnosed from registry date 1955 as of 12/31/17 = 99%. *Non-analytical, basal and squamous cell cancers of the skin and in-situ of the cervix are excluded from the calculations of follow-up percentage.

The abstracting timeliness was 93% of the 2017 cases abstracted within 5 months of the date of a patient’s first contact with the facility, 90% is the requirement by American College of Surgeons. The top five most frequently occurring primary site trends include Lung, Prostate, Colorectal, Liver and Hematopoietic.

We strive to provide the highest quality database. We endeavor to achieve this through uniformity of data collection, annual physician chart review of 10% of our new cases, software edits checks, and accurate and timely follow-up information on our patients. Our ultimate goal is to contribute to the prevention and cure of cancer.

The Cancer Program continues to support the registry’s educational activities which assist us to meet Standard 1.10; Cancer Registrar Education which includes participating in cancer-related educational activities other than cancer conferences.

2017 TUMOR BOARD REPORTBernice Williams, CTR

Our weekly Tumor Board is a conference which includes both case presentation and a didactic program. Following each presentation, there is discussion of the case and review of the recommended staging and treatment modalities available. This ensures a multi-disciplinary and multi-specialty approach to the treatment of disease as well as providing education to the house staff, students, and allied health professionals in attendance. Continuing Medical Education credits are given to the physician staff for Tumor Board.

During 2017, there were 168 presentations (138/82% prospective and 30/18% retrospective) of new primaries, recurrences or follow-ups. Sites presented included: Bladder, brain, breast, colorectal, esophagus, kidney, liver, larynx, leukemia, lung, lymphoma, melanoma, nasal cavity, neuroendocrine, oral cavity, pancreas, prostate, tongue, and unknown origin.

The Stratton VA Medical Center has several oncology related specialty clinics that oversee the ongoing multi-specialty care and treatment for Veterans with cancer.

PRIMARY SITE 2017/TOP 5* TOT ANA NO W- W- B- B- O- O- 0 I II III IV U N IN

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# L N M F M F M F A C

ALL SITES COMBINED 457 407 50   409 18 24 1 5 0  45

108

113

55

74

20 41 1

System: C00 Lip/Oral Cavity/Pharynx                                    

LIP 1 0 1   1 0 0 0 0 0   0 1 0 0 0 0 0 0

TONGUE, BASE     3 3 0   3 0 0 0 0 0   0 0 0 0 3 0 0 0

TONGUE, OTHER/NOS 4 4 0   4 0 0 0 0 0   0 2 0 0 2 0 0 0

PALATE 1 1 0   1 0 0 0 0 0   0 1 0 0 0 0 0 0

FLOOR OF MOUTH 2 1 1   2 0 0 0 0 0   0 1 0 0 1 0 0 0

PAROTID 1 1 0   1 0 0 0 0 0   0 0 0 0 0 1 0 0

TONSIL 2 1 1   1 0 1 0 0 0   0 0 0 0 2 0 0 0

OROPOPHARYNX 1 1 0   1 0 0 0 0 0   0 0 0 0 1 0 0  0

PYRIFORM SINUS 1 1 0   1 0 0 0 0 0   0 0 1 0 0 0 0 0

System: C15 Digestive Organ                                    

ESOPHAGUS 8 8 0   7 0 1 0 0 0   1 1 2 1 3 0 0 0

STOMACH 8 7 1   6 0 2 0 0 0   0 1 0 1 4 2 0 0

SMALL INTESTINE 1 1 0   1 0 0 0 0 0   0 0 1 0 0 0 0 0

COLON* 19 16 3   18 1 0 0 0 0   6 3 4 4 2 0 0 0

RECTUM* 10 10 0   9 0 1 0 0 0   0 1 0 2 2 5 0 0

ANUS/ANAL CANAL* 2 1 1   2 0 0 0 0 0   1 1 0 0 0 0 0 0

LIVER/INTRAHEPATIC BIL* 27 26 1   25 0 1 0 1 0   0 13 6 4 3 1 0 0

GALLBLADDER 3 3 0 3 0 0 0 0 0 0 0 0 1 0 2 0 0

BILARY TRACT – OTHER/N 2 2 0 2 0 0 0 0 0 0 0 1 1 0 0 0 0

PANCREAS 14 14 0   13 1 0 0 0 0   0 2 6 1 5 0 0 0 System: C30 Respiratory System/Intrathoracic Organs                                      

NASAL CAVITY/MID EAR 1 1 0   1 0 0 0 0 0   0 1 0 0 0 0 0 0

LARYNX 11 11 0   11 0 0 0 0 0   0 1 2 4 3 1 0 0

LUNG/BRONCHUS* 96 92 4   85 4 4 0 3 0   1 35 1023

25 1 0 1

THYMUS 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0

System: C42 Hematopoietic/RETICULO                                    

HEMATOPOIETIC/RETICULO* 31 26 5   27 2 2 0 0 0   0 0 0 0 0 1 30 0

System: C44 Skin

27 23 4   27 0 0 0 0 0  12 3 8 1 3 0 0 0

System: C49 Connective/Subcutaneous/Other Soft Tissues      

CONNECTIVE/SUBCUTANEOUS 2 2 0   2 0 0 0 0 0   0 0 0 1 0 1 0 0

System: C50 Breast

10 10 0   0 9 0 1 0 0   2 7 1 0 0 0 0 0

System: C60 Male/Genital Organs      

PROSTATE GLAND* 111 88 23   101 0 10 0 0 0   0 26 67 411 2 1 0

System: C64 Urinary Tract

KIDNEY 9 8 1   9 0 0 0 0 0   0 5 1 3 0 0 0 0

RENAL PELVIS 1 1 0   1 0 0 0 0 0   0 0 0 1 0 0 0 0

URETER 2 2 0   2 0 0 0 0 0   2 0 0 0 0 0 0 0

BLADDER 25 23 2   21 1 2 0 1 0  17 3 1 1 1 2 0 0

System: C69 BRAIN 1 1 0   1 0 0 0 0 0   0 0 0 0 0 0 1 0

MENINGES 1 1 0   1 0 0 0 0 0   0 0 0 0 0 0 1 0

System: C73 Thyroid/Other Endocrine 1 0 1   1 0 0 0 0 0   0 0 0 0 0 1 0 0

System: C77 Lymph Nodes 7 6 1   7 0 0 0 0 0   0 0 2 2 2 1 0 0

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System: C80 Unknown Primary 7 7 0   7 0 0 0 0 0   0 0 0 0 0 0 7 0

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CANCER CARE & SUPPORT SERVICES

CANCER SURVIVOR'S CELEBRATION Tess Thierbecker, LCSW, OSW-C

The Twenty Fifth Annual Cancer Survivors Celebration was held on Friday June 2, 2017. Approximately 200 cancer survivors, their guests and staff members attended the celebration of life that was held on the grounds of the Fisher House. The positive energy of the day was highlighted by the beautiful spring weather.

We are extremely grateful for the support of Voluntary Service and Committee members. The dedication and generosity of our volunteers has been an invaluable contribution to this annual celebration. The guest welcome was delivered by our hospital director, D. Scott Guermonprez, FACHE. We are extremely thankful to Jennifer Watson, our key note speaker, cancer survivor, and caregiver who shared her experience and appreciation to VA staff for excellent treatment and support.

Entertainment was provided by both Bob Marcello a gregarious performer drawing the crowd into a sing along and our very own Veteran cancer survivor, William Faye, singer/musician for the fourth year in a row. The colors were presented by the Lansingburgh Uniform Color Guard.

Our partners at the American Cancer Society were in attendance. Many beautiful items were also donated by staff, and volunteers that were used as door prizes.

Dr. Syed Mehdi our Chief Medical Oncologist delivered the closing remarks and highlighted the accomplishments and improvements in the Cancer program throughout the past year. Our Master of Ceremony was John McDonnell, “Mac”, who happens to be the retired Chief of Police at Albany VAMC.

 The VA Chaplain Service presided over the invocation and benediction. Pastries and coffee were provided by Voluntary Service. Volunteers helped with registration and distribution of T-shirts, pens and water bottles. A cook out was provided by Wal-Mart Distribution Center 6096, Johnstown, NY; we are extremely appreciative for their generosity for the sixth year in a row. The Johnstown DC 6096 staff has come to know our veterans and provided conversation, laughter and assistance with getting food to the table for veterans to enjoy.

This event was successful because of the collaborative effort, support and involvement of many dedicated employees and volunteers. The planning committee is comprised of retired employees/veterans and personnel from various disciplines within the medical center. Their unselfish involvement is proof of their dedication to our Veteran patients.

This year's celebration was again, a huge success. The planning committee is already looking forward to and beginning to plan for next year’s event.

WOMEN VETERANS REPORT Suzanne Deane, LCSW WVPM

The Women Veterans Program Manager (WVPM) along with our Women’s Health Medical Director continue to support and advocate for women’s health care and services at the Albany facility and our 11 Community Based Outpatient clinics (CBOC’s). The Women Veterans Health Committee, chaired by the WVPM, meets at least bi-monthly to address issues with our Women Veterans Program.

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Dr. Rachel Grimm, our designated Women’s Health Primary Care Provider continues to have new female Veteran enrollees assigned to her patient panel so they can receive “comprehensive primary care” which includes their basic gender specific care. Women Veterans who were already assigned to other providers who cannot provide this comprehensive primary care are given the opportunity to switch to Dr. Grimm’s panel. The “Wellness Woman’s Clinic” takes place every day for GYN except Wednesday which is a surgery day for our GYN provider. Women’s primary care is open Monday, Tuesday, Wednesday, Thursday, and Friday (1/2 days). Patients are seen either in the Women’s Wellness Center to ensure that every woman can receive her basic gender specific care in a separate space designated just for women and from an interested and proficient primary care provider.

Our GYN Provider Dr. Mesidor is full time with surgery time on Wednesdays. This gives our women Veterans a consistent provider face for primary care and GYN care in our Wellness Center. GYN Clinic is held every day except for Wednesday (OR day). There is also a GYN Surgical Care Coordinator who manages preoperative care for GYN surgical patients.

The current wait times for new and returning appointments in the GYN clinic is below 30 days. As our number of female enrollee’s increases, clinic time will be expanded to maintain access of less than 30 days. Women can access the VA Choice program for mammography if the VAMC cannot provide the service and/or the Veteran lives 50 or more miles from the facility. Same day nursing visits and urgent care scheduling is available.

The Albany VAMC GYN clinic offers a check in and waiting area. In the “Women’s Wellness Center”, the Women’s Health Primary Care Provider and the Gynecologist work collaboratively in this unit to provide women’s comprehensive primary care and GYN specialty care. Behavioral Health is available within the Women’s Wellness Clinic area to provide same day access to behavioral health services. The Women’s Wellness Clinic providers have begun a pilot program for screening all women Veterans who are seen for care for interpersonal violence (IPV) and can provide a warm handoff to the VA IPV Coordinator.

Thin Prep Pap tests with HPV testing are performed for cervical cancer screening. The GYN provider notes any pap tests that are positive and does follow up as needed. The GYN RN receives a monthly PAP report which is reviewed to ensure appropriate follow up was made. Mammograms are ordered by Primary Care providers or the GYN providers for breast cancer screening.

Patient education involves all staff in the Women’s Health Clinics. Staff has use of the Veterans Health Library, which offers a wealth of medical information to share with all Veterans.

Providers can send the Veteran the Women’s Wellness Clinic in Albany, or have an e-consult set up for a telephone consult and our GYN provider will call and speak with the Veteran about the best choices for that Veteran. The clinicians are planning to begin to expand services offered through telehealth.

QUALITY MANAGEMENTMarlene Herrington, BSN

The Medical Center’s Mission is to Care for our Veterans with Compassion and Excellence. Our vision is to be the Health Care Provider of Choice, achieving the highest Quality in Health Care Delivery,

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Education, and Research. We are committed to adding value to our mission by modeling our I-CARE Values: Integrity, Commitment, Advocacy, Respect, and Excellence.

Quality and appropriateness of care rendered to oncology patients is reviewed using the following criteria: Occurrence Screening Management of care Utilization review criteria Patient Safety/Risk Management Performance Measures and External Peer Review Program (EPRP) measures

Cases may have been subjected to clinical review, root cause analysis, and/or peer review as appropriate. Root Cause Analysis identifies basic reasons that cause or contribute to an adverse event or close call. The analysis focuses primarily on process design and organizational changes. Completed review requires lessons learned action plans, completion dates, and outcome measurement strategies. The reviewed timeframes for Performance/EPRP measures covers January 2017 through December 2017. The EPRP Quality Specialist provided training to Patient Aligned Care Team Medical providers and nursing staff regarding the EPRP measure modules and appropriate documentation of screenings. The results are as follows:

Colorectal Screening – 79.3% Cervical Cancer Screening – 83.5% Breast Cancer Screening – 79.4%

Some of the compliance of these measures is due to the patients not making their routine follow-ups within the year time frame (due to patient appointment preference) and some are due to patients re-scheduling appointments which are affecting the year window. Also, some measures are falling out due to the patients relocating to another facility. Patient refusal of a test/procedure also counts against our percentages. The Gastroenterology team is increasing their efforts to reach those patients who declined routine screening.

CHAPLAIN SERVICEBruce Swingle

Chaplain Service at the Stratton VA Medical Center affirms the following: By virtue of training and experience as pastoral care and health care specialists, chaplains are aware of the spiritual and moral dilemmas which often arise from the anxieties, problems, and fears which accompany illness and disabilities. The chaplain provides the kind of religious ministry, pastoral care, or just emotional support that seeks to meet the needs of the whole person in his or her struggle for health and peace of mind. The chaplain is sensitive to the variety of religious, spiritual, and cultural backgrounds of patients to whom ministry is provided.

A Welcome Space – On the eleventh floor of the medical center you will find our Catholic Oratory and our All Faiths Chapel. The Catholic Oratory is a faith-specific prayer room. The All Faiths Chapel is a religiously neutral area. Both locations are available to all Veterans, families, and visitors as places of welcome, prayer, worship, or simple quiet reflection.

Palliative Care Program – Chaplains continue to serve as active members of this team. We join with other staff to provide holistic care for our Veterans and their families. It is our privilege to work with patients and families in exploring their own spiritual nature and resources for health, wellness and hope.

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Bereavement Services – As chaplains we continue to express our care and hospitality for families through our active involvement in bereavement services. Through a letter of invitation families and friends are welcome to attend our quarterly memorial services. These interfaith services are held in our medical center’s All Faiths Chapel. Families and friends are invited to honor their loved ones through words and participation in a ritual of remembrance.

Ongoing Integration – We continue our efforts to have Chaplain Service and spiritual support integrated into patient care. Chaplains, with Veteran permission, coordinate the spiritual care of any Veteran within our facility who requests or desires such service. Through chaplain visits we can offer a formal spiritual assessment. Additionally, we provide emotional support and spiritual resources that are respectful of each Veteran’s spiritual beliefs, religious practices, and personal values.

Spirituality is an important element in holistic care. For many people their spiritual beliefs, personal values and religious practices are vital resources for coping, addressing existential concerns, and in making decisions. It is our privilege as chaplains to step into the circle of care with Veterans and their families during this time in their lives.

HEMATOLOGY/MEDICAL ONCOLOGY REPORT Syed Mehdi, MD

The Hematology/Oncology department continues to provide patient-centered care to our Veterans with excellence, kindness and respect. They receive standard of care in a timely manner.

The team consists of medical providers, nurses, a social worker, Research Coordinator, oncology pharmacists, palliative care, nutrition services, and a tumor registrar. The dedication and devotion are unparalleled. There is tremendous communication among all staff members. The infusion room nurses are the back bone of the department. They meet every morning to discuss all patients that receive treatment that day. They follow the National Oncology Nursing Society Standards (ONS) and their caring and compassionate attitudes are always appreciated by our Veterans. They spend a great deal of time explaining to the patients their treatment regimen, including the side effects, the toxicities, and follow up care. They also follow up with regular telephone calls after every treatment.

In addition, the oncology nurses are also involved in enhancing academic pursuits. They have been very much involved in process improvement which includes: implementation of a primary care model of each patient receiving systemic chemotherapy. Patty Minkler RN involved in educating the complex management of High Dose Methotrexate for Providers, Medicine Residents and Nursing Staff and development of Biotherapy SOP. Nicolle Martin RN is the peer leader for patient safety and Fall Committee. Both Patty Minkler & Nicolle Martin were presenters at local Oncology Consortium for area nurses.

Nursing students from Russell Sage often rotate through our infusion room and experience the professional aspects of nursing from our devoted nurses. Patty Minkler RN continues to participate in the local Northeast New York Oncology Nursing Education Consortium as both the Co-chair and Treasurer. In the role of the co-chair she coordinates with local hospitals to provide educational opportunities related to oncology nursing. All nurses continue to maintain their ONS chemotherapy/Biotherapy cards which positively impacts clinical care.

The integration of palliative care, nutrition and social worker into the Hematology/Oncology clinic has been a blessing to our veterans with malignancy. This has improved the timeliness to access services, symptoms management, and an optimal level of functioning/quality of life.

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Our Research Coordinator, Elisa Ball continues to help with clinical trials.

Bernice Williams, our Certified Tumor Registrar again performed a fabulous job with timely completion & reporting of all requirements for the American College of Surgeons(ACoS)

Our weekly tumor board continues to be highly educative and very well attended by all specialties. Our weekly liver tumor board also discuss cases from Buffalo and Syracuse VA.

NUTRITION AND FOOD SERVICES Regina Latourrette, MS, RD, CDN, CSO, CNSC

Nutrition and Food Services provides an extensive program including meals, nutritional assessment and nutritional counseling to meet the oncology patient’s nutritional needs. The nutrition department recognizes that the nutrition needs of a patient during cancer treatment and recovery differ based on the type of cancer, the stage and treatment of the disease.

The Registered Dietitian (RD) works closely with a multidisciplinary team of cancer specialists which includes: hematology and radiation oncologists, surgeons, nurses, otolaryngologists, and speech pathologists. The RD considers the intensity of certain types of cancer, side effects of cancer therapy and the patient's ability to eat when assessing nutritional status. The RD orders nutritional therapy which may include diet, oral nutritional supplementation, tube feeding regimens and counsels patients on ways to improve nutritional intake. Nutrition services are provided to Hospice as needed with an emphasis on providing comfort to these patients.

In October of 2017, the outpatient Oncology Nutrition Clinic was increased to Monday through Friday to meet patient needs. At that time the number of FTEE for dietitians in oncology increased from 0.5 to 1.0 FTEE. Providers may send a consult to Nutrition Outpatient to obtain services for their patients but consults are no longer necessary for patients to be seen in nutrition clinics. Patients can self-refer or the dietitian can receive an alert from any staff member to inform them that a patient needs to be seen due to a nutrition problem.

Nutritional screening by nursing and nutrition staff is routinely provided for hospitalized oncology patients. Nursing alerts the nutrition staff when nutrition risk factors are found. These patients receive further evaluation for nutritional risk. Nutritionally compromised patients receive a comprehensive nutritional assessment by a Registered Dietitian.

Once the dietitian is notified that a patient needs a nutrition intervention an appointment is made in the Outpatient Nutrition Oncology Clinic. The Registered Dietitian then completes a nutritional assessment. The assessment utilizes timely, pertinent information and compares gathered data to evidenced-based standards. Patients may require assessments and counseling in response to weight loss, compromised nutritional intake, or if they require nutritional supplements for more than 30 days. Counseling sessions include instruction on nutrition interventions to alleviate or minimize nutritionally related disease or treatment related side effects. A nutrition diagnoses is made identifying nutrition problems accurately and consistently. The RD works with the patient by refining or changing interventions to produce the desired outcomes. Per patient's request, family members can be included in nutrition clinic appointments. There were 246 appointments completed in the Oncology Nutrition Clinic in 2017.

To promote disease prevention, the Nutrition and Food Services department continues to promote the “MOVE!” program which is a national weight management program for Veterans. This program provides weight management services and focuses on maintaining a healthy weight, adopting a physically

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active lifestyle and eating a healthy diet which are recommended in the American Cancer Society Guidelines for Cancer Prevention.

ADVANCED ILLNESS COORDINATED CARE (AICC)/PALLIATIVE CARE CONSULT TEAM (PCCT)

Ishtpreet Uppal M.D.

The palliative care team continues to provide outpatient services in oncology. We have now been embedded in this clinic for the last 8 years. At present our team includes 1 FTE NP and RN, 0.6 MD, 0.3 Chaplin. We also have Social Work department pitching in with an additional 0.3 hrs. and behavioral health support to make an additional 0.3.

Although palliative care teams have been required by policy since 2003, in June 2017 an updated VHA directive outlining the role of palliative care teams was published. Approximately one-fourth of all Americans who die each year are Veterans, and 21,000 Veterans die in Department of Veterans Affairs (VA) inpatient care each year. This directive outlines the goals of palliative care teams and the mission to honor Veterans’ preferences for care at the end of life.

In June 2017 the Veteran Experience Center Clinical Brief on Quality of End-of-Life Care Provided to Patients with Different Serious Illnesses was also published. It concluded that nationwide between 2009 and 2012, 73.5% of patients with cancer received a palliative care consult. This was based on data from 145 VA Medical centers. This brief noted that Family-reported quality of EOL care was significantly better for patients with cancer and those with dementia than for patient’s other chronic diseases.

2017 marked an initiative from the VHA to train clinical providers in “Goals of care” discussions. From our facility PCCT NP, Susan Casler, took the initiative of championing the role out for the VISN. This training took place in Minneapolis. Dr. Julie Phillips from the home-based primary care team also received training. Together they have held 2-hour long training sessions for members of the Tumor Board/cancer committee. Additionally, LCSW Tess Thierbecker and RN Nicole Martin also received training and are now in the process of training other nursing staff, behavioral health staff and social workers.

In FY 2017 (January 1ST to October 31ST), 548 visit encounters were completed in our palliative care oncology clinic. Our average no-show rate was 14%.

2017 has also marked a VHA initiative to encourage telehealth and telemedicine. PCCT’s remains involved to offer appropriate veterans home telemedicine visits and telehealth visits in the rural clinics.In addition, we continue to offer ELNEC (End-of-Life Nursing Education Consortium) training. This program is offered to and attended our community hospice partners as well as facility staff.

SOCIAL WORK SERVICES Teresa Thierbecker, LCSW, OSW-C

The primary focus of the Oncology/Hematology/Radiation Oncology Social Worker is to provide psychosocial support and resource information to patients and families facing the challenge of cancer.  Many of the cancer patients treated in our institution have been served by social work.   Patients and families are offered psychosocial support as they receive their diagnosis and throughout the course of and following treatment.  They are also assisted in obtaining appropriate in-home and community services to enhance their quality of life. 

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The oncology social worker assists Veterans and their families in navigating through the health care system and provides assistance and reinforcement surrounding their diagnosis and education of treatment modalities.

The oncology social worker also manages the distress screening tool provided to patients at initial consultation.  Social work reviews all screening tools, and provides follow up contact to those patients who identify needs or concerns.  Further referrals are made based on the needs identified on the screening tool.

Emphasis is focused on providing patients and families with supportive counseling and assistance with concrete, practical issues that arise during cancer care as well as in the last phases of life, such as legal, financial, employment and family concerns.  Information and assistance are also provided to apply for eligible benefits, and/or assistance with the paperwork needed to take a leave of absence from work to tend to medical needs.

The Oncology Social Worker assists patients to meet the many challenges faced with End of Life Planning.  Advanced Directives are discussed with all new Medical Oncology and Radiation Oncology patients.  Paperwork is provided and completed, when the patient and family are prepared to do so. 

Furthermore, assistance and linkage with available VA and community resources for those facing the imminent death of a loved one and/or resources for those who have recently lost a loved one is available to patients via the Oncology Social Worker. Ongoing social work involvement ensures the continuity of care in the provision of outpatient, inpatient, transitional and Hospice Services.

SPEECH PATHOLOGYAlison Petro, M.A., CCC-SLP

Speech pathology provides services to cancer patients during the full continuum of their treatment.  Patients are seen for assessment and treatment of swallowing, voice, speech and/or language issues that occur because of their cancer and/or treatment.   Services provided include counseling, education, initial evaluation, and treatment, ongoing assessment during cancer treatment and follow up services after treatment is completed. 

Cancer patients referred for swallowing and/or communication services make up approximately one fourth of the total speech pathology caseload. Most referrals are for head and neck cancer patients but also include esophageal, lung, pancreatic and brain.

Most head and neck cancer patients treated by Speech Pathology have both swallowing and voice deficits, but some also include speech and articulation issues as well.  Sites include: oral cavity, tonsil, tongue, larynx, supraglottis, pharynx, and nasopharynx.  Patients are generally followed weekly during cancer treatment and monthly for the first year after treatment is completed. Some patients continue to be followed longer term for persistent, significant swallowing/speech/voice deficits.

Speech pathology continues to be actively involved in rehabilitation of total laryngectomy patients.  Most of advanced laryngeal cancers are treated with radiation and concurrent chemotherapy, decreasing the number of total laryngectomy surgeries done yearly.  There were only two new laryngectomy patients in 2017, up from one in 2016. Both were done as the primary treatment for cancer.  Rehabilitation involves teaching how to use the electrolarynx initially. Stoma management and use of heat and moisture systems are also included. Use and management of a voice prosthesis is completed for those who undergo trachea-esophageal puncture (TEP). Most patients with voice prostheses wear an indwelling model that requires periodic changing by the speech pathologist.  Trouble shooting and problem solving for complications that can develop with voice prosthesis is not uncommon in this patient population.  Speech will also work with

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laryngectomy patients on ways to improve their speech and trials of new products that are used with this population etc.

ENT and speech pathology continue to work closely together to manage treatment of head and neck cancer patients, often co-treating.  Speech Pathology also works with Radiation Oncology, Medical Oncology, Nutrition, Dental and other specialty clinics.  This comprehensive approach is essential to maximizing speech pathology services as well as overall benefit to the Veteran.

STRATTON VA & AMERICAN CANCER SOCIETY Partnership Summary Report 2017

Joni Richter

Cancer Information & Patient Support Services

Referrals to ACS January – December 2017 # RefsPatients by Channel 800-227-2345 20Local Office 31 Patient Referral Form 43

 

Service # of Patients # Provided

General Information/Personal Health Manager

94 94

SR Met w/Resource Referral

74 74

Support Group 3 3

Transportation

Hotel/Hospitality/Other

Look Good Feel Better

Reach to Recovery

Wigs

4

2

3

2

2

22

14

3

2

2

Highlights In 2017, the American Cancer Society (ACS) continued their long - standing partnership with Stratton VA to support their efforts in meeting the Commission on Cancer (CoC) standards of the American College of Surgeons. The American College of Surgeons CoC standards aim to improve the quality of cancer care in the United States. We at the American Cancer Society are happy to partner with Stratton VA Healthcare System, as they have been a CoC-accredited program for 50+ years and are a valuable resource for veterans and their families.  

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Part of this collaboration includes providing Cancer Resource Volunteers onsite, collaborating on annual cancer specific conferences for Veterans, staff and the community, and connecting cancer patients with local and national resources such as transportation, lodging, support groups, wellness programs, personal health managers, as well as other services available from the Society, local and national organizations, & local hospitals. We are proud to say that our “Cancer Resource Connection” database, with over 85,0000 resources is available free of charge on our website Cancer.org and that it contains thousands of local and national resources. We also make ourselves available to the public through this website and our National Cancer Information Center at 1-800.227.2345. 

CLINICAL RESEARCH

Elissa Ball

In 2017 we continued to follow the veterans enrolled in the CONNECT CLL and REVEAL Polycythemia Vera Registry trials. Twenty-six veterans were identified as having enrolled in the VA Million Veterans Program. The urologic trial “Phenazopyridine to identify ureteral orifices” continues to enroll subject with 16 being enrolled this past year. This investigation is using oral phenazopyridine in the place of other routine local dyes during cystoscopy to aid in the identification of ureteral orifices.

Prospective, Longitudinal, Non-Interventional Study of Disease Burden and Treatment of patients with Low-Risk Myelofibrosis (MF) or High Risk Essential Thrombocytopenia (ET) or ET Patients Receiving ET-Directed Therapy (INCYTE MOST) enrolled one subject over the past year.

One veteran was referred to Memorial Sloan Kettering for clinical trial participation and was enrolled in 3 trials.

A total of 46 subjects were enrolled to cancer related research studies in the year of 2017.

COOPERATIVE GROUP STUDIESProtocol # Title

Million Veteran Program: A Partnership with Veterans

INVESTIGATOR INITIATED TRIALSProtocol # Title

Phenazopyridine to identify ureteral orifices

INDUSTRY SPONSORED STUDIESProtocol # Title

CONNECT: The Chronic Lymphocytic Leukemia Registry- active REVEAL: Prospective, Non-interventional Study of Disease Progression

and Treatment of Patients with Polycythemia Vera in United States Academic or Community Clinical Practices-active

MOST: Prospective, Longitudinal, Non-Interventional Study of Disease Burden and Treatment of patients with Low-Risk Myelofibrosis (MF) or High Risk Essential Thrombocytopenia (ET) or ET Patients Receiving ET-Directed Therapy

Information regarding clinical trials is available by calling or contacting:Stratton VAMC Elissa Ball 518-626-6447 American Cancer Society 1-800-4-CANCERClinicalTrial.gov

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RADIOLOGY AND NUCLEAR MEDICINEF.S. Santos, MM, MBA/HCM, RT (R) ARRT

 Changes in medical imaging are driven by advances in technology. Improved and new technology allows further refinement of techniques in completing procedures in the diagnosis, staging, assessing response to treatment, and early detection of cancer. Well trained staff in Radiology and Nuclear Medicine offers several different types of imaging to serve our Veterans in Albany Stratton VAMC. 1. Nuclear Medicine- studies are performed from 0700 -1500 Monday to Friday for Nuclear Medicine (NM) and PET/CT. Requests can be accommodated as soon as the next day if needed. Imaging exams help in assessing tumor activity, lymph node involvement, and bone metastases. Pre- and post- treatment scans can be performed to assess the effectiveness of chemo and radiation therapies. Specialized studies for lymphatic mapping, neuroendocrine tumors, assessment of pulmonary function and left ventricle function after procedures and therapy are also available. The department has a GE PET/CT camera with a 64 slice CT for attenuation correction; Siemen’s Nuclear Medicine camera with a 16 slice CT for SPECT/CT imaging; low dose CT imaging is used in both NM and PET/CT for attenuation correction and fusion imaging for improved images. PET/CT imaging is also used in positioning treatments in coordination with radiation therapy and as part of treatment planning.

2. VIR – Specialized procedures, in addition to tumor ablation and chemo embolization, biopsy and localization of masses, continue to grow in the vascular and interventional radiology service line. The units have built-in safety and efficiency features that allow more imaging abilities utilizing lower doses of radiation. Smart masking allows contrast enhancement of structures by superimposition of reprocessed or prior images. The auto injector system monitors flow pressures and requires less overall contrast. Studies are available in-house 24/7, through VA interventional radiologists and contract services with the Albany Medical Center (AMC) Radiology Group.

3. MRI – The MRI unit is due for replacement which will convert the current system to digital broadband MRI providing flexible and intelligent tools for faster scanning and better patient comfort. The upgrade not only increases system versatility but also helps patient flow and clinical performance for a variety of applications. Radiology has extended MRI scheduling for patient access. Routine appointments are scheduled between 7:15AM – 5:00PM weekdays. Emergency services are provided on an on-call basis outside of administrative hours. 4. CT – Radiologists review all CT protocols for dose optimization and better interpretation eliminating unnecessary scan phases and establishing scan start and stop locations to particular areas of clinical interest. CT uses image correction software and tube current modulation to reduce overall patient exposure while still producing optimal diagnostic quality images. This technology is particularly beneficial on multiphasic studies which intrinsically have higher doses. Doses are documented for patient safety and record. Routine appointments are scheduled between 8:00AM-3:00PM. Urgent services are available in-house 24/7.

5. Mammography – An important and integral part of the Women’s Health program for screening and diagnostic follow up care of breast cancer, mammography exams are scheduled five days a week, M-F, 0800AM-3:30PM. Advancements in technology allows for the various screening tools that administer lower doses of radiation to the patients. Recent FDA inspection of our program is without exceptions for seven (7) consecutive years.

6. Ultrasound – Ultrasound is instrumental in early detection of masses and establishing its cystic and solid characteristics. Sonography continues to expand services to include vascular assessments and exams

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for other complications of tumors and its subsequent treatments. Routine appointments are scheduled from 7:15AM-4:00PM and STAT studies and add-on requests are accommodated by extending hours and on call tech for off tours period.

7. Diagnostic Radiographs and Fluoroscopes – New radiography systems enable better diagnostic imaging and upgraded fluoroscopy allow efficient and effective studies in screening and following up gastrointestinal and genitourinary tumors and other abnormalities. Two GE portable fluoroscopy C-arms with vascular angiography package enable capable intra-operative imaging support. Fluoroscopy exam doses are tracked and audited for safety and reported to the Radiation Safety Committee.

MAMMOGRAPHY REPORTLinda Carpinello-Dillenbeck R.T. (R) (M) (ARRT) Quality Control Mammographer

During this 23rd year of fully accredited ACR & FDA/VHA mammography; our team saw an increase in patient load; 857 female & male veterans. We were honored to serve Veterans who were interested in our Genius 3D Hologic Tomosynthesis Unit. We are proud to serve both female and male Veterans, employees & volunteers and Cancer Services Program Free Mammography Program community underinsured. This community screening program is also in its 23st year of participation in a national free mammography program. We continue to participate with the best breast imagers in the capitol region thru this community prevention partnership. With national healthcare screening regulations causing constant confusion our referrals have dwindled for all the CSP partners sites. Stratton VA received our Seventh perfect consecutive FDA/VHA on site Mammography Inspection in May 2017. In this time frame we completed our 2017 mandated Medical Audit and Correlation of Biopsy and prepared for our ACR 2D/3D Reaccreditation. During the IG review of the Women’s Program, Mammography team was mentioned with positive reviews.2017 was a strong and productive year. Review of Medical Audit for 2018: April 18,2017-April 17,2018 (mandated timeline for FDA inspection)829 patient mammograms for time frame of this Medical audit report (increased from 764 in 2016 Medical Audit). (Pure patients-CAD not counted).#1-Are all positives mammograms entered? Yes, all imaging from 4/18/17-4/17/18 (all bx results gathered for imaging up to 8/31/17 /Yes as extended review because of our INSPECTION was one month earlier and short radiology staffing). #2-Are bx results present or an attempt to gather? Yes, ALL ENTERED.#3-Is there a designated reviewing Interpreting Physician? Yes#4-Is the analysis done annually? Yes#5-Is the analysis done separately, for each MD? Yes#6-Is the analysis done for the facility as a whole? Yes See BELOW chart of VA 2017 rating as compared to Desirable Goals for 2016

Recall Rate (goal-<10%)=17%, which is lower since last year (last year recall rate was 20%). Note this is our third year with the 3D Tomosynthesis unit, which provides more detail imaging, in conjunction we have a Fellowship Diagnostic Mammography Radiologists on our staff that, requires more call backs and utilization of u/s, external MRI, Stereotactic Bx.& U/S Guided Core Bx are occurring. Lead Mammographer Linda assumed and continues in 2018 full phone call coordination of scheduling of screening & diagnostic patients to enhance & assure increased compliance with rescreening. On 5/8/18 we had our MSA cover all screening coordination. Interestingly the Veterans Choice Program of referring patients to local providers, caused a decrease in numbers in 2016, and a slow increase to 764 patients in 2017, and 829 in 2018(these numbers reflect the Medical Audit time frame based on our April 18-Anniversary date.) Many patients have returned, choosing Stratton once again. Continuous national good press on VA adopting ACS

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guidelines for female veterans has brought back increased patient loads. We are continuing to rebuild patient numbers with outreach of our 3D Tomo enhanced imaging, the Hologic Genius 3D Selenia 5000 Unit.

Cancer found per 1000 patients=9 (eight females and one male) breast cancers. (Last year we discovered 8). Nine malignancies found in 829 patients (goal 2-10 in a cohort of 1000!) EXCELLENT/GOAL MET.

PPV1-Positive Predictive Value based on abnormal findings at Screening= (goal-5-10%)=6.2% (last year 5.3%)/ GOAL MET

PPV2- When Surgical Biopsy (surgical, FNA, Core, Stereo) recommended=Cancer (goal-25-40%)=45%( last year 35%).Although this is outside the recommended range, the fact that nine cancers were discovered in 829 patients suggests that we have unusually high cancer rate in our population, possibly secondary to an overall older population and/or Veterans with environmental exposure.

Sensitivity-% of cancers detected by mammography-(goal>85%)=100% (last year 100%)EXCELLENT/GOAL MET-EXCEEDS GOAL**

Specificity-% (goal>90%)=98%(last year 97%)EXCELLENT EXCEEDS GOAL**

Note: Nine cancers found (eight females, one male. Five females choose to skip Mammography for three years. Two had MST problems, and complex family lives.Age is a risk factor and as female veteran age they often forget about screening.Consequently, larger cancers present 1cm and more; because of the three-year postponement of mammography screening. This date reflects the talent of the mammography radiologists, and the expertise they have learned in our third year of having the Selenia Genius 3D Tomosynthesis Unit. We are fortunate to have in house mammography radiologists Dr. Jomol Turinsky, Dr. Chrystina Czerwinskyj and Dr. Maithao Le and Dr. Richard Howard breast surgeons on our Stratton team.

OVERALL our Analysis of this MEDICAL AUDIT found six Applicable Goals: For 2017 we have achieved three EXCELLENT\Goals! All four were in range for our Simple Screening Audit Style. In this 2017 review 0ur diligent radiologist’s work continues to mirror the goals that are national standards, and reflects the team effort led by Dr. Jomol Turinsky Lead Mammography Radiologist and Dr. Chrystina Czerwinskyj Interpreting Mammography Radiologist. Our associate mammographer Mabel Pietraniello continues to increase her skills and is an asset to the team. This past year everyone has continued to work on the learning curve of this 3D system and we all have achieved our FDA Inspection. In addition, while conducting the patient care, and FDA preparatory work we had to renew a dual 2D & 3D American College of Radiology Reaccreditation.

PHARMACY SERVICEDavid Kupiak, R. Ph

Members of the Hematology/Oncology Pharmacy Department continue to be actively involved in the care of our many Veteran patients.  They serve as an authoritative information source on antineoplastic agents and on the many adjuvant and neoadjuvant treatment regimens. This would include, current dispensing practices and the proper technique for preparation of these medications within our sterile products mixing pharmacy.  The pharmacists are supported by a team of technical staff specifically trained in the preparation, handling and dispensing of antineoplastic agents for various treatment regimens.  Rick Grembocki R.Ph., Research Pharmacy Program Specialist, works closely with the hematology/oncology team to provide guidance, direction and oversight of Cancer Research Trials.  Dave Kupiak R.Ph., Lead Oncology Pharmacy Program Specialist, along with the Research Pharmacist and a team of chemotherapy

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trained clinical pharmacists and technicians; contribute to the design, conduct and evaluation of pharmaceutical related treatment regimens.  In addition, they participate in the evaluation and utilization of antineoplastic agents, under the auspices of the VHA Pharmacy Benefits Management Services, VISN 2 Pharmacy & Therapeutics Committee, Medication Use Committee, Quality Assurance, Cancer Committee, Tumor Board, Institutional Review Board, and Research and Development Committee.  Our treatment preparation pharmacy, within the 9th floor Cancer Treatment Center, is in full compliance with current Joint Commission requirements for pharmacy areas preparing sterile chemotherapy products. It is under constant review to maintain the most up to date chemotherapy preparation standards. In addition, planning has been under way this year for the implementation of a new round of practice standards that will be enacted shortly. Those standards called USP 800 along with the current USP 797 standards, will require further updates and modifications to our current preparation pharmacy. This work is ongoing.

Our staff participates in continuous training and continuing education. This ensures that our Veterans are receiving medications that are prepared following stringent guidelines, using properly trained and supervised staff. The Hematology/Oncology Pharmacy also serves as a training site for PGY 1 pharmacy residents as well as undergraduate pharmacy students from various colleges of pharmacy around the northeast. This includes, amongst others, Albany College of Pharmacy and Health Sciences. 

RADIATION ONCOLOGY Sudershan Bhatia, MD

The Radiation Oncology department at the Stratton VA Medical Center, Albany, NY is Accredited by the American College of Radiology (ACR).

We provide an essential treatment option for the care of Veterans diagnosed with various types of cancer. Multidisciplinary treatment decisions are made in collaboration with our medical and surgical oncology colleagues.

From January 1, 2017 to December 31, 2017 there were 252 consultations and 200 patients received treatment. There were 258 CT simulations and 510 follow up visits during this period. The most predominant diagnosis treated was prostate cancer at 26.5%. The second most common malignancy treated was lung cancer at 26%, and third was Head and Neck at 12.5%. 82.5% of the patients were treated with curative intent and 17.5% with palliative intent.

Radiation therapy is a highly technologically dependent specialty. Of 40 VAMC Radiation Oncology centers we are one of two hospitals with a Tomotherapy machine. All patients referred to Radiation Oncology are considered for treatment with advanced radiation techniques including: Intensity Modulated Radiation Therapy (IMRT), Image Guided Radiation Therapy (IGRT), Stereotactic Body Radiation Therapy (SBRT), as well as prostate seed implant brachytherapy.

With the installation of a new TrueBeam linear accelerator, we will soon expand services further to include Stereotactic Radiosurgery (SRS) for brain tumors, SBRT for liver tumors, and SBRT for prostate cancer. This will add convenience to eligible patients for highly effective short duration treatments.

Brachytherapy for prostate cancer is offered at our center and is performed with low dose permanent prostate seed implants. We are one of the very few Radiation Oncology programs in the VHA system to provide brachytherapy services. Our brachytherapy planning and delivery system offers state-of-the art treatment and delivery of precision brachytherapy for low and intermediate risk patients with prostate cancer.

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Additional staff include two RNs who maintain and update all patient education materials, a Social Worker, and 2 Registrar Dietitians, who provide excellent services to our Veteran patients undergoing treatment.The departmental policies and procedures continue to be updated annually by our physics, dosimetry and radiation therapy staff.

We are also actively involved with research to analyze efficacy of treatment outcomes to maintain quality assurance.

Our staff provides exemplary care to our Veterans. In addition, the staff continues efforts in teaching and research. Our staff mentors short term elective rotations for Albany Medical Center medicine residents. We continue to be a clinical education site of SUNY Upstate Radiation Therapy Technology students. The therapy students spend a semester in the Radiation Oncology Clinic and rotate through each area including treatment, dosimetry and nursing.

SURGICAL REPORTRebecca O’Malley, MD

The Stratton VA Medical Center provides a wide range of surgical services in multiple specialties for cancer patients.  They include general oncologic, hepatopancreaticobiliary, colorectal, otolaryngologic, urologic, and thoracic surgery services, as well a plastic surgery reconstruction services.  In addition, robotic approaches to colorectal, pancreatic, and urologic cancers are currently available to our patients.  Referral services include but are not limited to Pittsburgh VA Medical Center, Albany Medical Center, Albany Gastroenterology Center and the Woman’s Breast Center at St. Peter’s Hospital. Our surgical staff members have an active relationship with Albany Medical College and many hold academic appointments and/or dual appointments at Albany Medical Center. Albany Stratton VA staff actively participate in both internal and external continuing medical education activities and multiple surgical conferences by specialty at our own VA Medical Center, as well as at Albany Medical Center.

Our surgical staff members have attended and presented research at multiple nationally recognized conferences including; the Society of Surgical Oncologist Annual Cancer Symposium, the American College of Surgeons Clinical Congress, the American Urological Association annual meeting, the Society of Urologic Oncology annual meeting, the American Society of Colon and Rectal Surgeons annual meeting, and the American Association of Plastic Surgeons annual meeting, among others.  We regularly attend and moderate our weekly general tumor board meeting, our multidisciplinary liver cancer tumor board meeting and our biweekly multidisciplinary lung tumor board meeting at the Stratton VA as part of an effort to provide comprehensive cancer care for our VA patients. In addition, our surgical oncologist attends tumor board meeting at the Buffalo VA to help provide needed surgical care for patients with hepatopancreaticobiliary cancer.

The local surgical representative to the Cancer Committee is Dr. Rebecca L. O’Malley. She is a Board Certified Urologic Surgeon who is fellowship trained in Urologic Oncology.  In addition to being a full time urologic oncologist at Albany Stratton VAMC, Dr. O’Malley also manages the urology division as section chief. She actively participates in research with recent publications related to decision-making and patient outcomes in kidney cancer.

The Stratton VAMC continues to provide a plethora of cancer-related surgical services, patient support, and community outreach programs, and ongoing clinical research. All are considered central to the comprehensive care we provide for our Veteran patients

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Dental Service Cancer ProgramDr. Claudia Reyes-Lopez

The Stratton VA Medical Center Dental Service plays an integral role in the management of head and neck cancer patients. The three primary objectives of the Dental Service Cancer Program are:

(1) To participate fully in patient assessment and interdisciplinary treatment planning.(2) To establish optimum oral conditions for cancer therapy management.(3) To maintain effective recall for follow-up care of these patients.

On admission to the hospital, all suspected head and neck cancer patients are referred by consultation to Dental Services. Consultations are also received for patients diagnosed with head and neck cancer who’s plan of care includes Radiation Therapy. Each patient is assessed on an individual basis regarding their oral health and to develop a dental treatment plan which can be integrated into the overall cancer treatment plan (surgery, radiation and / or chemotherapy).

Early involvement of the Dental Service for evaluation and proper timing of any necessary dental treatment will provide appropriate integration of medical/dental care, reduce management complications, and best serve the health and welfare of the Veteran involved. The goal for early dental intervention is to optimize the Veteran’s oral health prior to surgical resection and/or chemo radiation treatment.

All patients are instructed in proper oral hygiene. Radiation patients are placed on a fluoride therapy protocol. All head and neck cancer patients are seen during radiation therapy to screen for any untoward oral sequelae such as mucositis, xerostomia, loss of taste, and radiation carries. Patients who experience any oral sequelae to radiation therapy are appointed follow up in the dental clinic on a long-term basis. Because of this stringent follow-up program, very few cases of osteoradionecrosis have been reported at this center.

Any acute dental problems are best treated prior to surgical, radiation or chemotherapy treatment. Routine dental treatment is reinstituted once the patient is ambulatory and comfortable following surgery, radiation and/or chemotherapy.

By assessing each patient in the pre-treatment phase, any necessary post-treatment prosthetic rehabilitation is facilitated, be it in the form of intraoral obturators, specialized prosthesis such as tongue bulbs or extra-oral facial prosthesis.

The annual survey was conducted on head and neck cancer patients identified during the 2017 calendar year based on data obtained from the Stratton VA Medical Center Tumor Registry. The purpose of this survey was to determine the percentage of patients identified with head and neck cancer that were screened, treated and/or followed by the Dental Service and/or referring VISN 2 Dental Services. The integration of CPRS (the VA computer patient record system) across VISN 2 allows us to view dental notes from other sites in our network.

The Dental Service receives consultations generated by the Head and Neck Pathway. The referring services send these patients to Dental Service for supportive care on a prn basis. Dental Service is represented at Tumor Board; consultations do get generated newly diagnosis patients.

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An interdisciplinary continuous quality improvement team had developed a head and Neck Clinical Pathway to insure timely notification and consultation with respective services provided for Veteran whose lesion is staged at T2 or greater lesion. We also depend upon ENT to set the clinical pathway in motion.

Our examination rate of head and neck cancer patients has been as follows: Calendar year 2006 28/30 93%

2007 34/39 87%2008 24/25 96%2009 25/30 83%2010 28/29 97%2011 34/40 85%2012 24/28 86%2013 14/16 87.5%

2014 20/23 87% 2015 17/28 60.7%

2016 22/30 73.3%2017 17/23 73.9%

The data was integrated into a table for an overview of patients identified and screened during 1983 – 2017. The data reflects a continuous improvement with respect to the multidisciplinary approach regarding the management of head and neck cancer patients. The number of Veterans referred to the dental clinic prior to their cancer treatment has increase 1%. Site-specific tables have been developed to illustrate the number of patients diagnosed at the Stratton VA and the number of these patients screened and/or treated by the Dental Service during 1983 - 2017. The Stratton VA Medical Center Dental Service plays an integral role in the treatment of such patients.

In 2017, 17 out of 23 patients were seen by the Stratton VAMC Dental Service. Of the six patients not followed/cleared by the Dental Service, one refused cancer treatment, 3 received palliative care without radiation therapy, 1 received radiation therapy and palliative care due to cancer recurrence and metastasis, and 1 patient did not have dental consult, he came directly from Syracuse to receive radiation therapy. He was followed by Syracuse ENT but did not see dental after his cancer diagnosis and prior to radiation therapy. Cancer incidence by site of those not followed/cleared include: Two oral cavity (floor of mouth and tongue, 1 pharynx (tonsil), and 3 Larynx (glottis and supraglottis). The Dental Clinic will continue to encourage the multidisciplinary treatment approach for head and neck cancer patients.

HEAD AND NECK CANCER PATIENTS 1983 – 2017

Tumor Site Number of Patient Identified

Number of Patients seen by Dental Svc.

% of Patient seen by Dental Svc.

Tongue 207 185 89.3%Salivary Glands 13 9 69.2%

Gingiva 20 17 85%Floor of the Mouth 102 95 93.1%

Other Mouth 111 102 91.8%Oropharynx 217 203 93.5%Nasopharynx 39 36 92.3%Hypo pharynx 139 125 89.9%Nasal Cavity 45 41 91.1%

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Larynx 489 417 85.2%Total: 1382 1230 89.0%

HEAD AND NECK CANCER PATIENTS SCREENED AND/OR TREATED BY DENTAL SERVICE

1983 – 20171983-87 1988-92 1993-97 1998-02 2003-07 2008-12 2013-16 2017

Tongue 39 31 30 25 24 12 18 6Salivary Glands 0 9 0 0 0 0 0 0

Gingiva 1 5 2 4 2 2 1 0F.O.M. 24 22 20 13 9 5 2 0

Other Mouth 27 18 14 14 14 7 7 1Oropharynx 21 38 28 29 31 41 15 0Nasopharynx 6 11 4 5 7 3 0 0Hypopharynx 35 25 26 11 12 12 4 1

Nasal Cavity Sinuses 6 13 2 4 9 5 1 1

Larynx 77 86 70 63 45 46 26 8Total: 236 258 196 168 153 109 74 17

HEAD AND NECK CANCER PATIENTS 1983-2017

INCIDENCE BY SITE

1983-87 1988-92 1993-97 1998-02 2003-07 2008-12 2013-16 2017

Tongue 41 35 33 29 24 14 24 7

Salivary Glands 0 13 0 0 0 0 0 0Gingiva 1 5 2 4 2 3 1 0

F.O.M. 25 22 20 15 9 5 3 1

Other Mouth 27 21 15 17 16 7 6 1

Oropharynx 23 39 29 31 31 44 19 1

Naso-pharynx 6 11 4 8 7 3 0 0

Hypo-Pharynx 36 25 27 14 15 16 5 1

Nasal Cavity Sinuses 6 15 2 4 9 6 2 1

Larynx 89 90 77 77 55 54 36 11Total: 254 276 211 199 168 124 96 23

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A Veteran’s Cancer JourneyBy Richard Loubriel

On December 31, 2013 after 30+ years of Active Army Service; I retired from the military. In June of 2016; I was diagnosed with Stage III Non-Small Cell, Lung Cancer. This is a brief story of my journey through Cancer and how the United States Department of Veterans Affairs saved my life.

On June 6th, 2016, I went to see my Primary Care Provider at the Albany Stratton VA Medical Center in Albany, New York. I asked him to give me his opinion about a lump that had just surfaced on the left-side of my neck just above my collarbone. He immediately scheduled me for an X-ray followed by a CT scan to determine the possible causes of the lump on my neck. Although the results of the X-rays were inconclusive; the CT scan showed something on my left lung (upper lobe) that prompted my doctor to refer me to the Facility’s team of specialist for more extensive test. The lesion on my lung was further confirmed by a PET scan which revealed multiple lumps of various sizes running up from my trachea tube extending to my neck. With a sense of urgency, I was scheduled for consultations with the Medical Oncology and Radiation Oncology Departments. My Oncologist, Dr. Syed Mehdi, Chief of the Oncology/Hematology Department, wanted to make sure my brain was not affected, so before I sat down with him an MRI and biopsies were ordered and successfully performed. After the blood work, diagnostic scans were completed and the biopsy results were available, Dr. Sudershan Bhatia and his Radiology Team; Dr. Syed Mehdi and his Oncology team along with Tess Thierbecker the Clinical Social Worker, worked together to develop a comprehensive treatment plan to fight my cancer. On July 11 of 2016, I was officially informed of my diagnosis and stage by Dr. Mehdi.

My first reaction was of total disbelief. The day of the official diagnosis; I could not think straight, I did not know what I was going to tell my Family; I did not know what was in store for me and my now bleak future. I suppose; I did what most people in my situation would do. I began researching everything I could about Lung Cancer and began to really look at my prospects and really prepared for the battle ahead. In my household we were no strangers to Cancer. My Wife of 30 years is a 13-year Stage IIIB Cervical Cancer Survivor. We knew that Cancer could not be beat with just medicine. The Cancer fights are won with a combination of things. It takes the right attitude, and an Army of dedicated Doctors from Oncology and Radiology, Nurses, Pharmacist, Radiology Technicians, other Technical Specialists, Social Workers, Nutritionists, Pathology, Laboratory Specialists, Surgical Teams, Spiritual Counselors, Palliative Specialists, and other Critical and specialize Staff; armed with the very latest medicine, advanced technologies, and cutting edge treatments along with the direct support of family, and friends working together in complete harmony to stop the spread of the disease. We prepared for the worst. Well, the worst never came. In fact, I do not expect it to come at all.

This outstanding team of people spared no expense or resource to ensure I had the greatest opportunity to beat Cancer. This is because here at the Albany Stratton Medical Center, every aspect of Veteran Care really means something. The facility truly practices what the VA is all about. I was surrounded by professionals fully dedicated to my every need. Available to me were the best of everything, literally the best. From the start everyone involved ensured every single aspect of my life and the carefully chosen therapy; tailored just for me, would have the maximum effect and optimum outcome against my disease.

I underwent a 30-day targeted radiation therapy. The latest technology and equipment was deployed for this purpose; combined with two rounds (14 days each) of chemotherapy. Although I was showing good progress during my treatments, something happened that left me emotionally empty and thrust me further into despair. This was now November of 2016. After completing the radiation therapy and 2 rounds of intense chemotherapy, new tumors showed up under my left axilla (left arm pit). This meant I had

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progressive disease during the therapy. A new series of tests were ordered; CT, PET, MRI and another biopsy confirmed the new tumors were of the same cancer. I was now a Stage IV Non-Small Cell Lung Cancer patient. Logic would have dictated that I was losing the battle. The Team at The Albany Stratton VA Medical Center did not think so at all. I remember the very first time I emotionally collapsed in front of my Oncologist Dr. Mehdi. His response still lives in me and it will do so for the rest of my life. He looked right into my eyes and said, “You are a strong man and have fought hard, we have other options, other treatments, I will fight for you and with you because you are a fighter”. “I will never stop fighting, for you stopping is never an option”

Dr. Mehdi felt that it was important for me to see and understand how much they were willing to do for me. Having place all my trust and confidence on the Albany Stratton VAMC Team, I felt that I had nothing to lose by looking at other options elsewhere. My wife and I set up an appointment with Sloan Kettering Cancer Center in New York City. Sloan could not see me until January 2017. When I mention my intentions to Dr. Mehdi at Albany, he felt that I could not wait that much longer for treatment. He advised me to undergo a new; recently FDA approved approach to fighting cancer. Dr. Mehdi recommended Immunotherapy. He warned me of all the possible side effects and made no promises. The level of confidence he had spoke volumes and was truly enough to convince me to follow his advice. I had no reason not to believe him…My life was in his and the entire Stratton Team’s hands. We proceeded with the new treatment right away on an every two-week cycle.

By the time my wife and I made it to the January 2017 Sloan Kettering Cancer Center consultation appointment in New York City, the tumors on my neck had significantly reduced in size and there were physical and visually noticeable signs of reduction in my left axilla as well. When we finally saw the Doctor at Sloan, he was impressed and completely satisfied with the VA approach to treating my Cancer. The doctor at Sloan Kettering said to us that they would be happy to take over my care but that in his professional opinion we were already in the best of hands, and receiving the very latest treatment available, more importantly I was positively responding to treatment thus he would not have changed a thing. This was honest validation that the work of the team at the Albany Stratton VAMC, and their outstanding commitment to care and service to our Veterans was above and beyond all expectations.

I am now a living Stage IV Non-Small Cell Lung Cancer Survivor. I am still under treatment on an every month cycle basis; but thriving and living an otherwise healthy normal life. I live each day and while I do continue to plan for my future, I do not consume my days worrying about tomorrow. I recognize that I am only one Veteran amongst hundreds of thousands, each of us with our own experiences and our own interpretations and our own stories on how the Department of Veteran’s Affairs has responded to our needs whatever they may be. One thing is clear; I am one of the many success stories within the Department of Veteran’s Affairs but mine defies all odds and restores confidence, faith, and gives hope where there was none. On my cancer journey; my life prior to and in its current state remained the same where the mundane of each day is revealed ever so subtly that sometimes I miss it without even realizing it. That is because I am fully aware of my fortune and I realize that I am still here because of the VA, its people and what they have done for me. A simple gesture of caring by the dedicated personnel of the Albany Stratton Medical Center has changed my life in ways I cannot even begin to describe. I will forever remain humbled by the experience and will forever be in their debt; ever so grateful for their exceptional performance, dedication, and tireless efforts to ensure our Veterans get the best of care. I have not witnessed a more capable, more dedicated, more decisive group of people anywhere else in my life.

My Cancer Journey is exactly that a journey; no different than a long road trip. It has its ups and it has its downs, curves, bumps and pot-holes. The journey is not a sprint to the finish line somewhere out there into the future but rather a steady forward progression towards an everyday life.

Two years have passed since I started my new Immunotherapy treatment and I am doing better than expected with-I dare say-no visible, physical or otherwise negative side effects. I have even put on some

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weight! Something Dr. Mehdi and I do not seem to agree or appreciate on merit. I am living an otherwise normal life. Most people have no idea of my condition and are always taken by surprise when I speak about it.

While I have had a few moments of pause, early this year when one of my CT scans prompted a PET scan because the interpretation of the CT scan may have shown a possible re-occurrence on my left upper lung; I approached it with the same level of confidence the Albany Stratton Team had demonstrated from the very beginning of my diagnosis. A PET scan revealed that no cancer activity was evident. A second PET, ordered by Dr. Mehdi; conclusively showed no cancer activity what so ever was evident throughout my body or any of the previously diagnosed locations.

On my scheduled check up with the Radiation Oncology Department; Dr. Bhatia, took the opportunity to really explained in detail the Cancer evolution within my body; from the beginning to my most recent PET scan. I was shown every slide ever taken by our Radiology Teams-whether PET or CT. The imperative importance of what I was seeing with my own eyes was how the Albany Stratton VAMC medical staff and collective body of professionals fought the disease to save my life.

It’s been two years, but it may as well have been described as an eternity or just a second in our cosmic clock; since time no longer holds a primary significance to my drive mainly because I now value each instance with equal respect. I remain grateful, humbled, and in eternal debt to God, my family and friends, the Department of Veterans Affairs, the Albany Stratton VAMC and its entire workforce for their dedication and true commitment to excellence. As a Soldier, I protected the Freedoms embodied in our Constitution and I was consciously willing to give my life for it.

As a Veteran, and VA Employee it is the most gratifying feeling to know every single day when I wake up that I am now part of a work force dedicated to ensuring our prime directive “To care for him who shall have borne the battle” are not just words…

Abraham Lincoln would be please to know they are not…I am a living example of that!

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2017 Study of Quality

Standard 4.7: Studies of Quality: Drop in Dental Referral with patients with Head & Neck Cancers Kathy France, RN and Ali Wazir, Medical Resident

Problem:Review of yearly data from VA Stratton Dental Service has shown a sharp drop of referrals from 2014 to 2105. In 2014 out of 23 patients with Head and Neck cancers 20 were referred to Dental service (87%). In the subsequent year of 2015, of the 28 patients with Head & Neck cancers only 17 were referred to the Dental service (60.7%). This represents the lowest yearly percentage in a ten-year period from 2006 -2015. (See table 1 below)

Calendar year2006200720082009201020112012201320142015

No. of Dental referrals28/3034/3924/2525/3028/2934/4024/2814/1620/2317/28

No. of Non-Referrals251516423

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Referrals Rate93%87%96%83%97%85%86%

87.5%87%

60.7%

Methods:A list of patients with Head and Neck cancers in 2015 was obtained from Tumor registry. Earlier as reported by service, 11 patients were reported not to have Dental Consultations. The charts of these patients were reviewed individually to elucidate the reasons for not obtaining standard of care Pre- Radiation with dental consultations (See Diagram 1 below)

Diagram 1

Results:The reasons for no dental consultation for patient with Head and Neck cancers diagnosed in 2015 are summarized in table below. (See Table 2)

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Had Referrals to Dental Service

17

Individual Chart review to determine

reason/reasons for non-referral to Dental

ServiceNot Referred to Dental Service

11Total no. of Head and Neck cancer patients in 2015

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Table2Sno

1234567891011

Site/StageGlottis/T4An2C/M0Lt TVC/MetastaticRt TVC/T2N0M0

Rt TVC/?Rt TVC/TisN0M0

Rt Sup-Glottis/T4N0M0DLBCL Ethmoid Stg IIMouth floor/T1N0M0

Rt Lat tongue/T4N1M0Tongue base/T2N1M0

Rt Tonsil/T2N2M0

Date of Dx04/27/201509/17/201506/08/201510/01/201510/28/201505/04/201512/14/201506/08/201505/06/201506/10/201504/22/2015

AADAADAAAAA

ReasonNot RT candidate due to med/psych issueReferral from Glenn falls, got RT there

Referral from Syracuse VAReferral from Syracuse VA

Was actually referred to Dental serviceNo clear Reason

RT was to Adrenal Met, not HENTT1 Lesion surgically resected

Referred & treated by Bath VA DentalNo clear Reason

Referral from Syracuse VAA=Alive D= Dead at time of this review. All tumors were SCC with exception of Sno.7 which was a DLBCL

The above list included Head & Neck cancer patients and NOT necessarily who received radiation. Hence Dental consult in all cases may not be applicable. Individual review of each case showed the following among the 11 patients (reported not to have dental consults): Dental consults NOT applicable Dental actually Involved No Dental consults

Patients # :1,7,8 2,5,9 3,4,6,10,11 Therefore, the total number of eligible patients decreases from 28 to 25 (3 not applicable)Out of 25 three of the patients were from Syracuse VA and 2 from our VA (Total 5)Hence 20/25 was referred to the Dental consult prior to RT (80%) (It was 87% in 2014) GUIDELINES: As per NCCN guidelines: All (100%) patients with head and neck cancer, who receive Radiation as a part of their treatment, should be evaluated by Dental service prior to initiating treatment

DESIGN A CORRECTIVE ACTION PLAN: Questionnaire were distributed to all providers involved in the management of Head & Neck Cancer to identify the knowledge deficit /process improvement for compliance with National standard guidelines.

ESTABLISH FOLLOW-UP STEPS to monitor the actions implemented: The Triage Radiation-Oncology RN facilitated the process to make sure all Head & Neck cancer patients being planned to start RT have a dental consult in place prior to initiating their first treatment.

At the recommendations of Cancer Committee Standard 4.7 was converted to Standard 4.8 Quality

Improvement -

6 providers questionnaires were completed. Causes for not referring to dental were identified:1) No Teeth, Consults,2) Few residents forgot to place the required consults, 3) Patients refusal

NCCN guidelines recommends all patients with head & neck cancer who will undergo radiation treatment should be referred to dentalOur referral was 80%, Cancer committee on 8/25/17 recommended to improve this by 10%.This quality improvement was to implement increasing the knowledgebase as well as diligent attention to referral pattern and to add the need for consults in the comment section which goes back to the requestor. As reported in last cancer committee meeting (2017) 100% eligible their first treatment.

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2017 Standard 4.8 Quality ImprovementVimala Thalody, MD/Beth Abrams, MD

"Burnout", as per a 1991 article in the Journal of Clinical Oncology “has been defined as the end result of stress in the professional life of a physician or caregiver resulting in apathy, suspicion, self-protection, disillusion, and depression. This not only affects patient care but results in serious deterioration in the personal and professional life of the physician. “(1) Provider burnout is reported to be across numerous surveys around 55 -60% in cancer care. (1, 4)

Some of the consequences of “burn out’ “include, suboptimal patient care, loss of provider empathy and compassion, increased likelihood of making medical errors, and poor patient adherence to prescribed therapy. Some of the personal consequences to providers identified are substance abuse, intent to leave medical practice, and suicide. (1, 2, 3)

One of several approaches to help deal with “burn out” is mindfulness practices. Some examples of mindfulness practices are meditation, prayer, journaling, being in nature, and breathing practices. (1, 4, 7)

The Breath–Body–Mind practice is a mindfulness technique that is taught at the Albany VA. This tool includes instruction in mindful grounding; coherence breathing and mindful body scan techniques. There is scientific research showing that such practices by modulating the parasympathetic and sympathetic nervous system can impact wellness, as well as many medical and psychological conditions. (7)

Benefits from mindfulness practices have demonstrated improvement in patient centered care both in the short and long term. (5, 6)

Breathing & Mindfulness based practices have been implemented in occupational settings to reduce stress in providers/employees. (5,6,7) Within our VA, after practicing Breath –Body –Mind, veterans and VA staff who participated, showed documented improvements in measures of Physical Exhaustion, Tranquility, Revitalization and Positive Engagement pre- and post-intervention.

The SVAMC Cancer program decided to offer all providers and staff involved with taking care of cancer patients, a voluntary work shop in Breath-Body Mind, as a data based quality improvement to the cancer program. By giving staff access to this tool, the data presented above, and shows there is improvement in patient centered compassionate care and provider / employee stress.

Two questionnaires were given to voluntary participants to fill out before and after the work shop. One was to evaluate if the work shop helped alleviate burn out symptoms subjectively. The second was to determine if caregivers would want B-B-M to be available for patients.

Summary:As a quality improvement for burnout, a mindfulness breathing workshop was organized by the committee in April 2017.Seventeen participants attended. 75% admitted to burnout, 88% wanted more access to these techniques. 100% felt the program should be available for patients. Exercise Induced Feeling Inventories were used, and those analyzed revealed Positive Engagement, Revitalization and Tranquility improved 22%, 58% and 30% respectively. Physical Exhaustion decreased 147%.

References-1. JCO 1991

2. JAMA, September 23/30, 2009—Vol 302, No. 12 3 West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006; 296(9):1071-1078.

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4. The Claude Organ Memorial Lecture: the practice of surgery: surgery as practice Mary L. Brandt, M.D.*The American Journal of Surgery (2009) 198, 742–7475. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program

In mindful communication with burnout, empathy, and attitudes among primaryCare physicians. JAMA. 2009; 302(12):1284-1293.

6. Beach MC, Roter D et all A Multicenter Study of Physician Mindfulness and Health Care Quality. Annals of family medicine vol 11, No 5421-428

7. Brown, RP, Gerbarg PL et all. Breathing practices for treatment of psychiatric and stress-related medical conditions. Psychiatry Clin N Am 36 (2014)121-140

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2017 AVAHO POSTERS

Is Hypomagnesemia a Marker of Efficacy of Cetuximab in Locoregionally Advanced and Metastatic Head and Neck Cancer?

Abstract 19: 2017 AVAHO Meeting Publish date: August 1, 2017Author(s): Azar I; Assi H; Esfandiarifard S; Asrani R ; Mehdi S

Background: Current NCCN guidelines recommend the use of cetuximab, an EGFR monoclonal antibody, in the treatment of head and neck (H&N) cancers in combination with radiation therapy as initial treatment of locally or regionally advanced disease in patients, who are ineligible for platinum-based therapy. It is also the standard of care in the treatment of recurrent or persistent disease with distant metastases.

Objective: Hypomagnesemia is a common side effect of cetuximab. Previous studies demonstrated that magnesium reduction was a potential marker of efficacy and outcome in the treatment of advanced colorectal cancer. We hypothesize that hypomagnesemia is also a marker of efficacy of the anti-neoplastic treatment of H&N cancer.

Methods: We retrospectively reviewed the medical records of H&N cancer patients that were treated with cetuximab between January 1, 2006 and January 1, 2016 at the Stratton VA Medical Center. Included in the study were patients aged over 20 years with stage III or IV H&N cancer who received cetuximab. Exclusion criteria included prior magnesium supplementation, history of treatment with anti-EGFR therapy, malabsorption syndromes and genetic magnesium wasting syndrome. Local IRB approval was obtained.

Results: Of the 63 patients studied, 23 developed hypomagnesemia for an overall incidence of 36.5%. The median age of diagnosis was 65 years for the hypomagnesemia group and 66 years for the nonhypomagnesemia. The patients that developed hypomagnesemia had a median survival of 27 months (95% CI, 16.3-37.6) while those that maintained normal magnesium levels had a mean survival of 20 months (95% CI, 12.3-27.7) (P = .583).

Conclusions: To our knowledge, no study has examined the predictive value of hypomagnesemia for the overall survival of H&N cancer patients treated with cetuximab that develop hypomagnesemia vs those that don’t. While data from the colorectal cancer suggest that hypomagnesemia may be used as a surrogate of efficacy for cetuximab, our data negates such correlation. Further study is required to elicit the link between cetuximab and hypomagnesemia.

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MULTIPLE MYELOMADONALD PASQUALE

The Stratton VAMC, Albany, New YorkStandard 4.6

The SEER data base estimates there will be 30,770 (1.8% of all cancers) newly diagnosed patients with multiple myeloma in 2018, with 12,770 (2.1% of all cancers) deaths.

We last reviewed our experience and outcomes with Multiple Myeloma in the 1984 (34 years ago) annual report. In 1984, myeloma was a rapidly fatal disease with median survivals less than 2 years and caused extreme morbidity severely impairing quality of life due to bone disintegration. Much progress has been made since then in advancing survival and quality of life. In 1984, there were basically 2 classes of agents effective in treating the disease both with a high side-effect profile preventing effective or chronic dosing. The predominant drug was the alkylating agent melphalan that while being quite effective and still used for bone marrow transplant conditioning, was quite marrow toxic. The second class of medications were steroids that continue to be used to date but due to the way these were dosed in 1984, while being active, had a high side-effect profile including worsening of bone disease (osteopenia due to steroid), and a very high infectious complication rate as used in 1984. Radiation therapy was and continues to be used for palliation of bone disease.

Advances in therapy for multiple myeloma started in the 1990’s when interferon, a non-chemotherapeutic agent, was introduced. However, the efficacy of interferon was low, and the medication was fraught with adverse effects. In the 2000’s, there has been an explosion of new ‘novel’ non-chemotherapeutic agents FDA approved for therapy of myeloma. These include the proteasome inhibitors (bortezomib with more potent second and third generation formulations now available), and the immunomodulatory agents (IMID’s) initially thalidomide, followed by lenalidomide and pomalidomide. Most-recently, targeted antibody therapy (daratumumab and elotuzumab) were approved in the 2010’s. Steroids continue to be an important part of the combinations, and the older alkylating agents continue to play a role in combination therapy for some patients. We are still learning how to best combine and sequence these novel agents. In addition to the disease control obtained with the newer medications, the introduction of bisphosphonates to protect patients from bone injury have also resulted in improved quality of life. The use of these agents has transformed multiple myeloma from a severe and rapidly fatal cancer, to more a chronic disease with median survivals over 5 years.

Review of our outcomes from 1984 indicated a median survival of 9 months for the most-advanced stage, about 12 months for intermediate stage, and 28 months for very early stage (some of these patients would not be treated today undergoing active surveillance). This review includes patients with multiple myeloma who were diagnosed between January 2007 and December 2017. Kaplan-Meier relative survival estimates were derived. There was a total of 64 patients with mean age of 70 years. Overall 5-year relative survival for the entire cohort was 42.4% (median of 40.6 months). Data is illustrated in the Table and Figure 1.

1973-1982 2007-2017 2007-2011 2012- 2017 SEERN= 21 64 28 36Mean ±SD Age 70 ± 9.8 71 ± 10 69 ± 10 65Median Survival (Mo) NA 40.6 15.5 63.5 NA

5-Year Survival (%) 24 42.4 26.6 54.6 50.7

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When we compared outcomes for the cohort diagnosed between 2007 and 2012 with the cohort diagnosed between 2013 and 2017, we found an extremely gratifying statistically significant improvement in the 5-year relative survival, 26.6% (median of 15.5 months) in the earlier cohort, versus 64.6% (median of 63.5 months) in the latter (Figure 2).

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We are delighted to indicate that our 54.6% 5-year relative survival exceeds (not statistically significant) the 50.7% 5-year relative survival described nationally for multiple myeloma as reported in the SEER database especially as the mean age of our patients is 5-years older than the SEER!

We believe that over the next 10 years additional tools will become available such as CAR-T and other immunotherapies that are currently in clinical trials, and hope that when we next review our experience with multiple myeloma, results will be even better so that we may be able to hazard speaking the “C” (CURE) word.

This report complies with requirements for American College of Surgeons COC standard 4.6.1. Sources for Assessment. All cased of Multiple Myeloma that were diagnosed at the Stratton VA

Medical Center between Jan-2007 and Dec-2017 were identified and included in this analysis.2. The first course of therapy, when indicated, were concordant with evidence based American Society of

Hematology (ASH) and/or NCCN guidelines.3. This analysis provides the opportunity to recommend performance improvements

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CONTRIBUTORS

The Cancer Committee would like to extend appreciation to the following contributors to this year's Cancer Program Annual Report. The scope of this information would not have been as extensive without their contributions and support.

Linda Carpinello-Dillenbeck, R.T. (R) (M) (ARRT) Quality Control Mammographer Alison Petro, M.A., CCC-SLP – Speech PathologyBruce Swingle - Chaplain ServiceFelicisimo S. Santos, MM, MBA/HCM, RT (R) ARRT - RadiologyRichard Loubriel – Veteran and Employee

The Comprehensive Cancer Committee would like to dedicate this Annual Report to Richard Loubriel for his continuous commitment to the Veterans, Cancer Program and to the staff of the Stratton VAMC.

We “Thank You” for your service!

.

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