VA Puget Sound Health Care System Cancer Program 2015 Annual

C a n c e r P r o g r a m A n n u a l R e p o r t

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INSIDE THIS REPORT

• Chairman’s Message

• Cancer Registry Report

• TumorBoardActivities

• Oncology Clinical Trials

• Hospital &Specialty Medical

Care–OncologyDivision

• Marrow Transplant Unit

• Head&NeckCancerService

• RadiationOncology-Cancer

Care report

• Special Report on Lung Cancer

OutcomeandSurveillance

Imaging_2015

• DiagnosticImagingServices

• Urologic Oncology

• GI Cancer Care

• NutritionandCancer

• WholeHealth:providing

patient-centered,personalized

andintegrativecareto

Veterans with cancer

• CancerCareNavigation

• Oncology Social Work

• Cancer Screening and

PreventionReport

• CancerRehabilitationCare/

RehabilitationCareService

• PalliativeCareandHospice

Service

• Pulmonary Medicine

• Spiritual Care

• Credits

Chairman’s MessageChairman’s MessagePeterC.Wu,M.D.,F.A.C.S

The mission of the VA Puget Sound Cancer Care Program is to provideexcellent multidisciplinary andcompassionate care to our Veterans diagnosed with cancer. With a 2014 reported caseload of nearly 1,000new cancer patients, our centercontinues to rank among the mostcomprehensiveandbusiestVAcancercenters in the United States.

There were several noteworthyeventsthispastyear.Weunderwentour triannual Commission on Cancer accreditation review and awardedwith Commendation Gold status byoursitereviewerwhocommentedtoour facility leadership that among the numerous VA facility cancer programs thathehasreviewedinrecentyears,the VA Puget Sound stands out for beingthemostcomprehensiveandinnovativeprogramwithawideofferingofclinical trials thatbenefitcancerpatients inourregion. Lastyear, theVISN20Cancer Care Platform Initiative provided the necessary funding to createour Cancer Care Navigator Team (CCNT). Under the leadership of TamarindKeating,ARNP, theCCNTteamatPugetSoundhasbecomewidelyrecognizedwithexpandedrolesintocancersurvivorshipandmanaginginterfacilitycancerreferralstoimproveoverallqualityofcare.WehavealsojoinedaVAconsortiumled by the Boston VA to support and expand clinical trials sponsored by the SouthwestOncologyGroup. With theadditionofon-sitePET-CTcapability toourestablishedradiationoncologyandbonemarrowtransplantationprograms,weofferanextensiverangeofcancerservices.

The 2015 Annual Report highlights the wide-range of services and clinicaltrialsofferedwithintheVAPugetSoundCancerProgramandrecognizestheimportantcontributionsfromallservicelinesanddepartments.WethankourlocalandregionalVAleadershipfortheircontinuedsupportoftheCancerCareProgramandcontinuetostrivetoprovidethehighestqualitycancercareforournation’sveterans.

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Cancer Registry ReportSudarshanaDas,COCCancerProgramManager &CancerRegistryManager,CTR

(Continued on next page)

Cancer statistics and cancer relateddata are an indispensable contributor to cancer research and outcome mea-surement,oneoftheforemostweap-onsinthefightagainstcancerdisease.

In2015theprojectednumberofnewcancer diagnoses in the USA will be 1,658,370 and an estimated 589,430cancer deaths, according to the Na-tionalCancerInstitute(NCI)&Ameri-canCancer Society (ACS) projections.The Annual Report on the Status of Cancer is jointly authored by subjectmatter experts at NCI, CDC (Centersfor Disease Control and Prevention),andtheNAACCR(NorthAmericanAs-sociationofCentralCancerRegistries).

Everthoughtwherethisdataoriginatesfrom?Allcancerstatisticsstemsfromgrass-root level collection of cancerdata at local hospital cancer registries by specially trained staffs, which arethentransmittedtostateandnationalcancerdatabasesformultipleuses.Forexample,theNationalCancerDatabase(NCDB)developedin1988byCOCandACS,containsapproximately32millionrecordsfromcancerregistriesat1,500COC-accreditedUShospitals.SEERda-tabase is another example.

A cancer registry collects and accu-rately records the clinical journey ofa cancer patient starting from diag-nosis to treatment received and alsoconductslife-longfollow-upofcancerpatients to enable survival and out-come related studies and research. It is therefore imperative thataccurate,highqualitycancerdataiscollected&analyzedbycertifiedcancerdataspe-cialistsi.e.CTRs(certifiedtumorregis-trars),withspecializedtrainingforthepurpose.

Uses for Cancer Registry Data

Cancer Registry data has innumer-able uses, including cancer researchandoutcomemeasurement,analyzingpatterns of care and quality of care,evaluatingtheeffectivenessofcurrenttreatmentmodalities,developingedu-cational programs, early detection/screening cancer programs, and canhelp leadership in making informed decisions for hospital expansion, re-source allocation and other businesspurposes.

Example-COC-CQIPreportusingNCDBdata from VAPSHCS registry:


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Cancer Registry Report (Continued)

VAPSHCS Cancer Registry

The VAPSHCS Cancer Registry is man-aged by a facility employed Cancer Program Manager/CTR and the bulkof registry work is contracted out to qualifiedvendorchosenby theVISN-20 Contracting Office. Best PracticesGroupisourcurrentvendorforcancerregistry work.

VAPSHCSCancerRegistryparticipatesand provides data for special studiesconductedatourfacility,oratnational

levelforpatientcarequalityimprove-ment studies, and for all other validpurposesasrequested.

The Registry also regularly submits data to various national databases,including VA Central Cancer Registry (VACCR), Commission on Cancer-Na-tional CancerDataBase (COC-NCDB),WA State Cancer Registry (WSCR)through Cancer Surveillance System(CSS), NCI/ SEER. All data submittedareperdata-useagreements&areag-gregate data with patient identifiers

and protected information removedduring data submission.

VAPSHCS Cancer Registry Data, com-plete year 2014

In2014,863analyticcasesofcancer,and113non-analyticcases,foratotalof976cancercaseswereaccessionedinto the cancer registry database.

The top ranking cancer primary sites seen at our facility in 2014 were Pros-tate,Lung,Hematopoietic&PlasmaCell,Melanoma, Colo-Rectal, Head & Neck,Bladder,Liver,LymphomaandKidney.

Glossary of Terms:Abstract:asummaryorabbreviatedre-cordthatidentifies,acancerpatient’sdiseaseprocessfromtimeofdiagnosistillpatient’sdeathincludingdiagnosis,staging, cancer treatment.This formsthe basis of a cancer registry.

Accession: to enter a reportable can-cer case following national rules andguidelines into the registry database.AnalyticCaseload:Cancerpatientsdi-agnosed and/or received first courseof treatment at VAPSHCS.

AmericanCollegeofSurgeons(ACoS):a professional organization of sur-geonsandphysiciansfoundedin1913,which has supported standards for hospitals, formationof registries,andaccreditsqualitycancerprogramsna-tionwide through its Commission onCancer(CoC)accreditation.

Caseload: the number of new cancer cases annually entered into a registry

CDC: Centers for Disease Control and Pre-ventionisafederalagencyoftheDepart-mentofHealthandHumanServices.

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Certified Tumor Registrar (CTR): thecredentials granted to a person whohaspassedthecancerregistrycertifi-cationexaminationbytheNCRA,andsignifies specialized knowledge andeducation for accurate collection, re-cording and analysis of cancer data into registry databases.

Commission on Cancer (CoC): a divi-sion of the ACoS, consisting of over

professional organizations involved incancercontroland improvingsurvivalandqualityof life for cancerpatientsthrough standard-setting, prevention,research, education, and monitoringofcomprehensivequalitycare.CoCac-creditedcancerprograms,suchasVAPugetSoundHealthCareSystem,sig-nifies establishment of performancemeasuresforprovisionofhigh-qualitycancer care and is nationally recog-


Cancer Registry Report (Continued)

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nized by JC (formerly JCAHO), ACS,CMS,NQF,NCI,tonameafew.

CSS: Cancer Surveillance System col-lectspopulation-baseddataoncancerincidenceandsurvivalin13countiesinwesternWashingtonState,andispartoftheSurveillance,Epidemiology,andEndResults(SEER)programoftheNa-tionalCancerInstitute(NCI).

DUA:DataUse Agreement, as requiredbyVAnationalpoliciesforsharingofdata.

First Course of Treatment: Cancerdirected treatment planned and ad-ministered,usuallystartedwithinfourmonths of diagnosis or as determined by the managing physician.

NCDB:National CancerDatabase is anationwide oncology outcomes da-tabase for more than 1,400 CoC-ap-

provedcancerprogramsintheUnitedStates and Puerto Rico. Approximately 75percentofallnewlydiagnosedcas-es of cancer in the United States are capturedattheinstitutionallevelandreported to the NCDB.

NCRA: National Cancer Registrars As-sociationisanot-for-profitassociationwithaprimaryfocusofeducationandcertification,representingCancerReg-istryprofessionalsandCertifiedTumorRegistrars(CTRs).

Non-Analytic Caseload: Cancer pa-tientswhowere both diagnosed andreceivedfirstcoursecancertreatmentat outside facility, and at VAPSHCSeither for treatment of cancer recur-rences, persistent disease, or, otherreasons like pathology reports only,surveillance/follow-uponly,etc.

SEER:afederallyfundedconsortiumofpopulation-basedcancerregistries,es-tablishedbytheNationalCancerActif1971tocollectandpublishinformationoncancerincidence,mortality,survivalandtrendsovertimeintheUS.

References:1. VACentralOfficeCancerProgram,

http://www1.va.gov/cancer/2. CommissiononCancer,https://

www.facs.org/3. NationalInstituteofHealth,http://

www.nih.gov/4. VHAHandbook1605.02,http://

www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2858

5. AmericanCancerSociety,http://www.cancer.org/

6. PreviousAnnualReports7. CancerRegistryManagement

Principles&practice,Hutchison,Menck,Etal.

The VA Puget Sound Health Care System Tumor Board is held everyWednesday from 1:00 p.m. to 2:00 p.m. in Building 100, Room BD-152.Tumor Boards provide clinical infor-mation,pathologicstaging,andtreat-ment recommendations for the pa-tient’sdisease.

The Tumor Board is composed of a multidisciplinary group of attend-ing physicians, fellows, residents,physician assistants, nurses, medi-cal students, and other health careprofessionals. Staff representatives

TumorBoardActivitiesfor2015Victoria Campa(CompileddataisfromJan.2014throughOct072015)

from Medical, Surgical, and Radia-tion Oncology act as discussants.All surgical subspecialties are repre-sented. Images and micrographs are presented by staff physicians fromDiagnostic Radiology and Pathology.The conference provides a forum todisseminate the most current infor-mation on cancermanagement. Thediscussantsreviewdatafromcurrentpublicationsanddetermineeligibilityofpatientsforcooperativegrouptri-als sponsored by the Southwest On-cology Group (SWOG) as well as in-house clinical trials. The conferences

providecontinuingmedicaleducationand provide a convenient forum forexpeditious management decisionsofcomplexpatients.

In2015,therewere38conferencesfortheyear.Allthemajorcancersiteswererepresented in the cases discussed. The averageattendanceateachconferencewas 23. Attendees can receive onecredithour continuingmedical educa-tioncategory1persession,whichcanbeappliedtowardre-licensurerequire-ments in Washington State.

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All requests forTumorBoardsubmis-sion shall be ordered online in CPRS on theorder tab.The requesting servicemust complete the consult template and includeareason for therequest.

Tumor Board Activities (Continued)

TumorBoard2015-Distributionof348TotalCases(1/1/2015–10/07/2015)

HEAD&NECK 86 24.7%

MUSCULOSKELETAL 15 4.3%

SKIN 8 2.3%

BREAST 1 0.3%

GENITOURINARY 8 2.3%

OPHTHALMIC 3 0.9%

LYMPHOIDNEOPLASMS 12 3.4%

CENTRALNERVOUSSYSTEM 3 0.9%

NON-CANCEROUS 0 0.0%

OTHER 0 0.0%

UNKNOWN 22 6.3%

DIGESTIVE 75 21.6%

THORAX 113 32.5%

All consult requests will be coordi-natedthroughVictoriaCampa,TumorBoard Coordinator, Oncology Section(6-4757).


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OncologyClinicalTrials-2014finaldata&JanuarythroughApril27,2015interimdataJeannineBartonandStephanieMagone

Clinical trials in oncology are studies that test, and often compare, treat-ments in a specific group of patientswithagivencancer.Clinical trialsde-fineandadvancebest treatments forpatient care. Through some clinicaltrials, patientsmay also access noveldrugs for treatment of their diseases. Cancerclinicaltrialsarethereforeavi-talpartof thecareoncologypatientsreceiveattheVAPugetSound.

VAPugetSoundactivelyparticipatesasamemberinstitutionoftheSouthwestOncologyGroup(SWOG)andNCI-Clini-calTrialSupportUnit(CTSU)/NCI-Nation-alClinicalTrialsNetwork(NCTN).Cancerpatientsarealsoofferedparticipationinthe Fred Hutchinson Cancer ResearchCenter (FHCRC) peripheral blood stemcell (PBSC) transplant protocols. In ad-dition, cancerpatientsareofferedpar-ticipationinappropriatepharmaceuticalindustry-sponsored studies with noveltherapies,aswellasin-houseprotocols.ExamplesofVAsupportedpharmaceuti-cal industry-sponsored studies include;chemotherapy combination regimensprior to stem cell transplantation andto reduce the risk of side effects fromstem cell transplantation, preventativemedicationstoreducechemoradiother-apysideeffects,advancedstagecancertreatment options, new chemotherapyandimmunotherapytreatmentoptionsfordifferent typesofcancers,andpre-ventativevaccinestudiesinpatientsdi-agnosed with cancer.

Our commitment to clinical trials in-volvesamultidisciplinaryteamofphy-siciansincludingmedical,radiationandsurgical oncologists as well as physi-cians of other surgical and medical subspecialties.Patientswithheadand

neck,thoracic,gastrointestinalandhe-matologic malignancies are discussed at the multidisciplinary tumor boardand are offered clinical trial participa-tion by the oncology research staff.PatientsareonlyreferredtoVAPugetSound approved research studies.Stem-cell transplant patients are en-rolledinsponsoredprotocolsapprovedby the VA Puget Sound as a part of their routineclinicalcare.

Allpatientsdiagnosedwithcancerthatare seen by a physician at VA Puget Sound are pre-screened by the Clini-cal Research Coordinators regarding eligibility for enrollment in a clinical trial. Oncepre-screened, if apatientappears to be eligible for a clinical trial, the patient’s treating Physician,Clinical Research Coordinators, and/or clinical trial Principal Investigator/Physicianwill present information re-gardingtheclinicaltrialtothepatientfor their consideration of participat-ing in the clinical trial. Informationabout actively enrolling clinical trialsatVAPuget Sound is available in theresearch kiosks throughout the facil-ity, displayed on the reader boards

throughout the facility, and availableonhttps://ClinicalTrials.gov.

In2014(finaldata),63cancerpatientsatVAPugetSoundelected topartici-pateinclinicaltrials.Withinthese63enrolled patients, 9 patients enrolledin treatment related clinical trials,18 patients enrolled in preventativetreatment trials, 24 patients enrolledinqualityoflifetrials,and10patientsenrolled in other types of cancer re-lated trials.

Todate,in2015(interimdata),18can-cerpatientsatVAPugetSoundelectedto participate in clinical trials. Thispercentage for clinical trials enroll-ment was compiled from enrollment datagatheredJanuary1,2015throughApril 27, 2015, but may not reflectthefinal clinical trial enrollmentdatafor 2015. Within these 18 enrolledpatients, 4 patients enrolled in treat-mentrelatedclinicaltrials,11patientsenrolledinqualityofliferelatedtrials,and3patientsenrolledinothertypesof cancer related trials.

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Hospital & Specialty Medical Care–OncologyDivisionDanielY.Wu,MD,PhD

The VA Puget Sound Oncology Divi-sionprovidesinitialmedicaldiagnosis,medicaltreatment,andfollow-upcarefor Veterans diagnosed with cancer. Thedivisionworks closelywith surgi-cal subspecialties and Radiation On-cology to offermultidisciplinary care;andwithsocialwork,nursing,dietary,chaplaincy,andotheralliedhealthcareservices toprovideholisticcare.Careand treatment for cancer patients isfrequentlycoordinatedthroughamul-tidisciplinaryTumorBoard. In this fo-rum, individualcasesandtherapeuticoptions are reviewed by representa-tives from all services and a consen-sus recommendation is rendered.Oncology nurse coordinators from the Oncology Division ensure follow-up,coordinates diagnostic and therapeu-tic recommendations, and maintainscontact with the patient. In addi-tion,awell-staffedCancerCareClinicprovides ongoing chemotherapeutic,transfusion, and supportive servicesforpatientsundergoingtreatment.

TheOncologyDivisionprovidescareinbothinpatientandoutpatientsettings.Patientsareevaluatedandfollowedatfour weekly subspecialty outpatientclinics staffedbyattendingphysicianswho are also faculties of the Univer-sity of Washington and fellow physi-ciansfromtheFredHutchinsonCancerCenter. Chemotherapy and treatment related care is provided in the newlyremodeled Cancer Care Clinic that op-eratesfivedaysperweekandstaffedbytwophysicianassistants,twonursepractitioners, three to four RNs, andone clerk. This unit provides all ofthe outpatient chemotherapy for VAPuget Sound Health Care System pa-

tientsandalsooffersaconvenientlo-cationforoutpatientprocedures,suchas bone marrow aspirates and physical examinations, outside of the regularoutpatient clinic hours. A full-timeclinical pharmacist manages chemo-therapy for both inpatients and out-patients, and ensures safety of drugadministration.

Recently, the Division has added afourmember cancernavigation teamto support patients who must travelgreat distances or are challenged with difficult personal issues. This naviga-tion team, consists of a nurse practi-tioner, a nurse coordinator, a socialworkerandaclerk,maintainscontactwiththepatientandprovidesthrough-outhis/her cancer care journey. Thenavigationteamalsoensuresseamlesstransition of the patient back to thereferralfacilityandprovider.Addition-ally,theteamwillprovidesurvivorshipcounselingtopatients,whohavecom-pleted treatment.

The Marrow Transplant Service re-mains amarquee program of the VAPuget Sound Oncology Division. TheMarrowTransplantUnit(MTU) isoneof only three such units nationwideunder the national VA program. TheMTU performs approximately 50-60transplants per year on patients re-ferred from both remote and regional sites. The MTU works in close col-laboration with the Fred HutchinsonCancerResearchCenter,andthetreat-ment and experimental protocols for transplantation are shared betweenthe two institutions. After the acutetransplant phase, the MTU performsoutpatient follow-up on transplanted


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Hospital & Speciality Medical Care (Continued)

patients as well as annual long-termfollow-up.TheMTUisadiscretephysi-cal patient care unit with integratedoutpatient and inpatient care, and adedicated nursing and clerical support staff. Theunitoperates full-timeandmanagestransplantpatients24/7.

Asalways,theOncologyDivisionsup-ports theoverall directionof theVAPuget Sound Cancer Committee, amultidisciplinary committee thatmaintains accreditations and pro-motes cancer care activities of theinstitution. As apartof themissiontoprovideVeteranswithcuttingedge

cancer care, the Oncology Divisionalso actively maintains a clinical re-search program. We provide clini-cal trial participation opportunitiesso that patients can have access tonovel drugs and advanced oncologi-cal concepts. Our clinical research programparticipates in anumberofstudies throughnational cooperativeprograms and pharmaceutical spon-sors;andisstaffedwiththreeclinicalresearch coordinators. The Oncology DivisionadditionallymaintainsalocalcancerregistryunderacertifiedCan-cer Registrar; and undergoes regu-lar clinical and system improvement

evaluations under a full-time qualityimprovementcoordinator.

TheOncologyDivisionisacentralpartof the VA Cancer Program,which hasreceived continuous distinction as acomprehensive cancer center desig-nated by the Commission on Cancer. The marrow transplant unit has been awarded multiple achievements andcertificatesofexcellencebytheNation-alMarrowDonors’Program.TheentireOncologyteamstrivesdailytoprovidesuperior care to our Veterans whom haveservedthiscountrywithhonor.

Marrow Transplant Unithttp://www.pugetsound.va.gov/marrowtransplant/Welcome.aspThomasR.Chauncey,M.D.,PhD

The Marrow Transplant Unit at the VA Puget Sound Health Care System was founded in1982. It operates in con-junctionwiththeSeattleCancerCareAlliance, Fred Hutchinson Cancer Re-search Center and the University ofWashington School of Medicine. The San Antonio VA began performing marrow transplants in 1986, joinedbytheNashvilleprogramin1995.To-gether,thethreeVAtransplantcentersprovide comprehensive marrow andstem cell transplantation services forVeterans with a variety of malignantand nonmalignant hematologic disor-ders.

Since 1982, well over 1,400 patientshavebeentransplantedinSeattle, in-cluding over 200 from unrelated do-nors. Utilizing 8 inpatient beds and1 outpatient suite, 60-70 transplantsareperformedyearly.Seattlepatientsreceiveinfusionofmarroworperiph-

eralbloodstemcellsfromthemselves(autologoustransplantation)orfromamatched or closely-matched relativeor unrelated donor (allogeneic trans-plantation). Allogeneic transplantrecipients, especially those receivingstem cells from mismatched and un-related donor sources, require pro-longed immunosuppression and are at riskforavarietyofcomplications.Im-munologictoleranceultimatelyoccurswithtime,althoughclosemedicalsur-veillance can be required formonthsto years. The longitudinal follow-upcare and clinical advice provided bythe Seattleprogram is a keyelementto the successful transplantation forpatientsthroughoutthecountry.

The largest proportion of VeteranstreatedinSeattlehavereceivedtrans-plantsformultiplemyeloma,followedby non-Hodgkin’s lymphoma, acutemyelogenous leukemia (AML), Hodg-

kin’s disease, chronic myelogenousleukemia (CML),andchronic lympho-cytic leukemia(CLL). Multiplemyelo-ma,non-Hodgkin’slymphomaandCLLcan be service-connected conditionsfor Veterans with prior Agent Orange exposure. Other malignancies and nonmalignant hematologic disorders areconsidered for transplantationonacase-by-casebasis.

Clinical research projects performedat the Marrow Transplant Unit in con-junction with the Fred HutchinsonCancer Research Center have led toimproved safety and efficacy ofmar-row transplantation, making curativetreatmentsavailabletoabroadernum-ber of patients. Outcome data frompatients transplanted at the MarrowTransplant Unit at the VA Puget Sound Health Care System compares favor-ably to published data in the medical literatureandnationalsurveys.

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Head&NeckCancerServiceMarcD.Coltrera,MDandJeffreyJ.Houlton,MD

More than 60,000 Americans (andmorethan900,000peopleworldwide)are diagnosed with head and neck (H&N)cancereveryyear.Becausevet-erans have disproportionately highratesofsmokingandalcoholuse,thetwo greatest risk factors associated withthedevelopmentofH&Ncancer,many of these Americans are our na-tion’sVeterans.

At the VA Puget Sound Health Care Sys-tem (VAPSHCS), cancers of the headand neck are the third most common solidtissuecancer.OurHeadandNeckCancerServicetreatsover50newcan-cer patients and 40 recurrent cancerpatients each year, making it one ofthebusiestVAH&Ncentersnationally.

The diagnosis of these H&N cancers canhaveadevastating impactonourpatients’ lives. These cancers impairthe most basic functions responsiblefor our daily quality of life, including:eating,speaking,andbreathing.Thesecancers also impact our vital senses,suchastaste,smell,hearing,voice,andsight. In addition, these tumors fre-quently distort our patients’ outwardphysical appearance further contribut-ingtosocialisolationanddepression.

Fortunately,we havemade significantprogress in the care of patients withH&N cancer. Thanks in large part to advancements in technology, novelsurgical techniques,andorgan-sparingtreatments (which take advantage ofnovel equipment and treatment pro-tocols), we have made remarkableimprovementsinthequalityofourpa-tients’livesduringandaftertreatment.

AttheVAPSHCS,weareoneofasmallselect number of VA centers that per-

formmicrovascular freetissue recon-struction for defects following headand neck cancer resections. Thesemicrovascular techniquesprovideourpatients with the highest form andfunction achievable following tumorremoval.Inaddition,weofferourla-ryngealcancerpatientslarynx-sparingtrans-oral laser surgery, an alterna-tive to total laryngectomy. This mi-croscopic surgical technique allowsourpatients topreserve themajorityoftheirlarynx,maintainingboththeirvoice and the ability to breath with-out a stoma. Our newest surgical ad-vancement involvestrans-oralroboticsurgery.Roboticsurgeryisanexcitingnew technology that allows tumors of the tonsils and base of tongue to be removed through the mouth ratherthan through amore extensive openoperation. Whenusedappropriately,thistechniqueseemstosparepatientsintensivechemotherapyandradiationwhichwaspreviously thestandardofcare for treatment of these tumors (given the morbidity of open opera-tions). Reduction in chemotherapyandradiationmayhavean importantimpact on our patients swallowingfunctionandoverallqualityoflife.

By offering the complete gambit ofoncologic and reconstructive surgicaloptions,weattheVAPSHCSH&Npro-gram distinguish ourselves as one ofonlyaveryfewselectcenterswiththeabilitytoofferpatientsallstate-of-the-arttreatmentoptionsavailable.Evenso, themost importantaspectofourH&Ncancercarecontinuestobeourability toworkas a focusedmultidis-ciplinary team. Our H&N team con-sistsofsurgical,medicalandradiationoncologists, neuroradiologists, nursepractitioners, nurses, social workers,

speech pathologists, and psycholo-gists. Our team meets each week to discuss all new head and neck can-cerpatientspresentedatourmulti-disciplinarycareconference (TumorBoard).Thiscollaborativeapproachensures that our treatment plan is beinguniquelytailoredtoeachindi-vidualpatient.

Wealsocontinuetohavecross-insti-tutionalcollaborationsamongstcen-ters in the region. We are partnered withphysicians at theUniversityofWashington Medical Center, wherethemajorityofoursurgicaloncolo-gists,medicaloncologists,andradia-tion oncologists hold appointmentson the faculty. We have researchcollaborationswithfacultyfromtheUniversity of Washington and theSeattle Cancer Care Alliance. Theseprogramsofferexcitingprogressto-wards treating patients with Head& Neck cancer. We believe that itis through these multidisciplinary,cross-intuitional collaborations thatwe will be able to obtain our ulti-mate goal: to achieve the highestpossible cure rates, while offeringthe highest possible quality of lifeforourVApatientslivingwithHead& Neck cancer.


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RadiationOncology— ContinuousQualityImprovementThroughTechnologicalAdvancesandUpgradesTonyS.Quang,MD,JD,AdamTazi,PhD,andKentE.Wallner,MD

The VA Puget Sound Health Care Sys-tem is a radiation oncology referralcenter in theVeteransAffairssystem,which is the first radiation oncologyfacility in the State of Washington ac-credited by the American College of Radiology. It provides cancer care forpatientsfromtheVANorthwestHealthNetwork20whichservesAlaska, Ida-ho,OregonandWashington. Wede-liver state-of-the art care to patientsdiagnosedwithvariousmalignancies.

Technological advancesandupgradesare actively implemented and everyopportunity is seized to streamline thecancercaredeliveryprocess.Thiseffortisspear-headedbytheradiationoncolo-gists—TonyS.Quang,MD,JDandKentE.Wallner,MD,physicistsAdamTazi,PhDandCarlBergsagel,MS,anddosimetristsSharonHummel-Kramer,CMD,ARRT(T)andDavidCain,CMD,ARRT(T).Thisef-fort is not only founded in best clinical practice,butfortifiedwithinterdisciplin-ary robustness.

Since January2015, for treatmentmo-tionmanagement,weimplemented4DCTsimulationformostofourearlystagemedically inoperable lung cancer pa-tientstotreatlesionswithtightertreat-ment margins to increase tumor control anddecreasetreatmenttoxicities. ThePinnacle radiation treatment planningsystem has been upgraded to version9.8.ElektaSynergytreatmentmachinesnow include on board imaging XVI sys-temupgradedtoversion5.02.

Our bone marrow stem cell trans-plant program is unrivaled with theimplementationofsaferandlesstoxicmyeloablative and non-myeloblativeregimens both in clinical and research settings.InJune2015,were-commis-sioned Elekta Synergy 1 linear accel-erator to treatpatientswithhighen-ergyphotons,18MVinsteadof6MV,forbetterdoseuniformity.InOctober2015,westartedtreatingtotalbodyir-radiationpatientswith18MV.

Furthermore,we have started to up-grade themostup-to-date versionofthe electronic medical record—MO-SAIQManagement System to version2.6byupgrading the twosequencerswhich would allow us to perform au-tomatic tablemovement when usingkV-pairforplanarimaging.Implemen-tationofthislatestversionwouldalsoallow for automated scriptingandanadditional layer of treatment verifi-cation and quality assurance whichmeetsnationalstandards.

While intensity modulated radiationtherapy (IMRT) continues to be usedtotreatheadandneck,prostate,lung,and rectal cancers, volumetricmodu-latedarttherapy(VMAT),afasterandbetter technique of radiation thera-py delivery, is being commissioned.This process involves reconfiguringour treatment planning to treat with SmartArcandvalidating theplanneddose versus delivered dose with the

Arc Check Phantom. We have alsogotten approval to obtain extra net-work space for Pinnacle so we can plan complexcasesusingSmartArc,whichrequiresmorespaceforcomplexplancalculations like for head and neckcancers.InSeptember2015,wecom-missioned Pinnacle Treatment Plan-ning System to plan with Smart Arc. WewillstartVMATtreatmentdeliveryinmid-2016.

Dr. Quang, Dr. Wallner, Dr. Tazi, Mr.Bergsagel,Ms.SharonHummel-Kram-er, andMr. Cain continue to improveclinical and technical treatment preci-sionbyoptimizingprotocolsfordose-volumeconstraintsandconebeamCTimaging to include specific treatmentsites. Ms. Hummel-Kramer and Dr.Quang worked with resident physi-cian,MichaelGensheimer,MDtode-velop amathematicalmodel predict-ingsuccessinparotidglandsparingforhead and neck IMRT treatment plan-ning.Thisalgorithmaddsefficiencyasit predicts success in planning allowing boththedosimetristandtheradiationoncologist to have reasonable expec-tationsofparotidsparing.Thefindingswere presented at the 55th ASTRO Annual Meeting in Atlanta, Georgiain 2014, and the fullmanuscriptwassubsequently published in the Medi-calDosimetry journal. Currently,Drs.Quang andWallner areworkingwithresident physician, Patrick Richard,MD,MSandAnaFisher,LICSW,OSW-C

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onaresearchprojecttoexaminepsy-chosocial factors based on the NCCN StressThermometerForPatients.

Wecontinuetoperformsolidcontinu-ous quality improvement includinginterdisciplinary chart rounds, out-comesstudies,focusstudies,andpeerreview. Onaweeklybasis,wehaveincorporatedthereviewofCTandMVimaging as part of our weekly rounds tomonitorpatientsetup.Drs.QuangandWallnerareactiveparticipantsatweeklyTumorBoardmeetingswherepatientsareofferedtheoptimalman-agement recommendations throughan interdisciplinary effort. Dr. Quangruns monthly clinical case conferences whileDr.Wallnerrunsmonthlyjournalclubs teaching residents atUniversityof Washington Medical Center. They areVisitingOncologyLecturersatBel-levue College teaching clinical oncol-ogytoradiationtherapystudents.Stu-dentsfromthistrainingprogramhaveconsistently over the years scored inthe90thto95th-percentile.

Asanationalauthorityonthequalityassurance effort of other VA brachy-therapy programs, Dr. Wallner haspioneered a specialty clinic in the ad-ministration of seed brachytherapyforprostatecancerpatients.Ourcliniccontinues to offer brachytherapy toprostate cancer patients who comefromeveryregionoftheUnitedStates.We have integrated brachytherapy

with a prostate cancer program that includes IMRT with placement of gold seedfiducialsfor imageguidedradia-tion therapy (IGRT). Using a shortercourse— hypofractionated radiationtherapy treatment has allowed pa-tients to complete their treatmentquickersotheycangobackhome.

RadiationOncology continues toplaya strong leadership role in the VA sys-tem.Dr.QuangwasrecentlyelectedasBoardMembertotheAssociationofVAHematology/Oncology,anorganizationwith members who are interested in advocatingandpromotingcancercareofVeterans.Dr.QuangalsopresentedtheVALarynxIIHypofractionationpro-tocol highlights at the AVAHO Annual MeetinginWashington,DC.Dr.QuangprovidesourVAwithup-to-datescien-tificandbestclinicalpracticeexpertisein his respective roles as Co-Chair ontheVA InstitutionalReviewBoardandSurveyor for the American College ofRadiology.HealsoservesastheVAIn-stitutionalPrincipalInvestigatorfortheSouthwest Oncology Group (SWOG).Dr. Quang continues to be an activememberof the IntegratingHealthcareEnterprise inRadiationOncology (IHE-RO)planningandclinicaladvisorycom-mittees.IHE-ROworksincollaborationwiththeAmericanSocietyforRadiationOncology (ASTRO), which addressesways to improve theuseof computersystems for information sharing,work

flow, and patient care. He alsoserves on the ASTROBylaws Com-mitteeandisViceChairoftheYoungPhysicianSectionoftheWashingtonStateMedicalAssociation.

The VA Puget Sound RadiationTherapy Department has main-tained its position as a nationallyvisible center drawing referralsfrom other VA facilities through-outtheUnitedStates.Ourpatientcensus remains stable. Our depart-ment continues to strive to suc-cessfully implement technological advances and upgrades to offerstate of the art cancer care. Our expansionofcuttingedgetechnol-ogy, continued innovation efforts,andourcommitmenttoqualityas-surance through the implementa-tionofarobustcontinuousqualityimprovement has positioned ourdepartment to offer our patientsthe best of care for now and well into the future.


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LungCancerOutcomesandSurveillanceTamarindKeating,ARNP,MPH

Lung cancer is the second most com-mon cancer among Veterans. An av-erageof130casesof lungcancerarediagnosed each year in Veterans re-ceivingcareattheVAPSHCS.1 Veterans are at higher risk for lung cancer com-paredtocivilians,withstudiesestimat-ingratestobe25-76%higherthanthenational average.2-4 Reasons for thisincludeahigherprevalenceoftobaccouseaswellasoccupationalexposuressuchasAgentOrange,asbestos,dieselfuels,andoilfires.

Between2010and2013,443casesoflung cancer were diagnosed or treated atVAPSHCS.Atthetimeofdiagnosis,95(21%)ofVeteranshadstageIcan-cer, 46 (10%)had stage II, 110 (25%)hadstageIIIand192(44%)hadstageIV lung cancer. 1

The cancer stage at diagnosis is a ma-jorfactorinpredictingsurvival;rough-ly 35% of Veterans with stage I or IIcancerwillbealiveinfiveyears,com-pared to just 7%and1%ofVeteransdiagnosed with stage III and IV lung cancer,respectively.1

Surveillance for cancer recurrencePatients have a 13-20% cumulativerisk of developing a second primarylungcancerintheirlifetime.5 If caught atanearlystage,roughlyhalfofthesepatientscanundergocurativetherapywithathreeyearsurvivalrateof48%.6Multiple agencies have developedevidence-basedguidelinesforsurveil-lancefollowingtreatment,howeveritis not always clear which medical pro-vider or service is responsible to en-suring surveillance is completed andguidelines can be difficult to accessand implement for providerswhodonotroutinelycoordinatethiscare.

To investigate whether Veterans re-ceived appropriate surveillance fol-lowingtreatmentoflungcancer,chartreviewswereconductedfor44Veter-ans diagnosedwith stage I, II, or IIIAlung cancer and treated at VAPSHCS. Based on the guidelines from the Na-tionalComprehensiveCancerNetworkthat recommend imaging with a chest CT scan every 6 months for the firsttwoyearsposttreatment,thenannu-ally, the study defined compliance ascompletingachestCTscanwithin4-8

monthsoftreatmentcompletion. Al-mosthalf (43%)ofVeteransdidhaveappropriatescreening,14%hadnoCTscan performed in this time period,and the remainder had scans per-formed too early or too late.7

Ofinterest,VeteransweremorelikelytohaveaCTscanperformedintheap-propriate follow up period when they were followed at the VAPSHCS com-paredtothosereceivingfollowupcareat other sites.7 CT scans were most fre-

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quently ordered in the correct timeinterval by surgeons or primary careproviders, compared to oncologists orothertypesofprimarycareproviders.7

ThisdatafavorablycomparestoalargestudythatassessedthesamequestioninaSEER-Medicaredatasetandfoundthatonly25%ofpatientstreatedwithdefinitivetherapyforlungcancerhadtheirfirstsurveillanceCTattheappro-priate time interval.8 There is clearly room for improvementhowever,par-ticularly for Veterans who will havetheir surveillanceperformedatothersites within VISN 20.

References1. Puget Sound VA Health Care System

Cancer Registry. 2.Dall,TM;Zhang,Y;Chen,YJ;etal.

Costassociatedwithbeingover-weightandwithobesity,highalco-holconsumption,andtobaccousewithin the military health system’s TRICAREprime-enrolledpopula-tion.AmJHealthPromot2007;22:120-139.

3.Helyer,AJ;Brehm,WT;Perino,L.

Economicconsequencesofto-bacco use for the Department of Defense,1995.MilMed1998;163:217-221

4.HarrisJE.Cigarettesmokingpractic-es,smoking-relateddiseases,andthecostsoftobacco-relateddis-abilityamongcurrentlylivingU.S.Veterans. Report Commissioned by the Department of Veterans Af-fairs Assistant Secretary for Policy andPlanning.1997.

5.Johnson,BE;Cortazar,P;Chute,JP.Secondlungcancersinpatientssuccessfully treated for lung can-cer.SeminOncol1997;24:492-499.

6.VanMeerbeeck,J;Weyler,J;Thibaut,A;etal.SecondprimarylungcancerinFlanders:frequency,clinicalpresentation,treatmentandprognosis.LungCancer1996;15:281-295.

7.Backhus,L.Privatecommunication.8.Backhus,L;Farjah,F;Zeliadt,SB;et

al.Predictorsofimagingsurveil-lanceforsurgicallytreatedearly-stage lung cancer. Ann Thorac Surg 2014;98:1944–1951.


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DiagnosticImagingService(DIS)JulieTakasugiMDandJosephGRajendran,MD

Diagnosticradiologyandnuclearmed-icineareimportantfieldsindetection,diagnosis,treatmentandfollowupofavarietyofdiseases, includingmalig-nancies. Diagnostic Imaging Services(DIS) is responsible for the perfor-mance of quality examinations, in-terpretation of those examinationsand for the communication of studyresults to the referring clinician in a timelyfashion.AttheVAPugetSoundHealthCareSystem(VAPSHCS),Seat-tleandAmericanLakeDivisions,thereare8receptionists/schedulers,2pro-gram support persons, 1 administra-tive officer, 2 PACS administrators,3 file clerks, 2 health technician/es-corts,50radiologic/nuclearmedicinetechnologists,5technologystudents,1.5 FTENursePractitioners, 1nurse,8residents,2fellows,9full-timeand2 part-time attending physicians. At-tending radiologists subspecialize inabdominal imaging, cardiothoracicradiology, gastrointestinal radiology,neuroradiology, musculoskeletal ra-diology, nuclear medicine (diagnosisand therapy) or vascular and inter-ventionalprocedures.

ServicesprovidedbyDIS includecon-ventional radiographic exams, fluoro-scopic studies of the gastrointestinaland genitourinary tracts and nervoussystem, computed axial tomographic(CT)scans,ultrasoundexams,magnet-icresonanceimaging(MRI),angiogra-phy and radionuclide studies. Modern CT, SPECT/CT and PET/CT scannershavebeen installed.ThecurrentPET/CT is a collaborative effort with R&Dinproviding clinical PET scan capabil-ity at VAPSHCS and we have startedofwith18F-fluorodeoxyglucose imag-ing. Mammography is performed at

Virginia Mason, UW, and other localimaging centers that are accessible to patients. Percutaneous biopsies,aspiration and drainage of fluid col-lections, biliary and genitourinarydrainage,long-termintravenouscath-eterplacement,percutaneousfeedingtube placement, tumor embolizationandablationprocedures,intra-arterialchemotherapy access and intravascu-lar stent placement are some of the diagnosticandtherapeuticproceduresofferedbythisdepartment.Innuclearmedicine, all generalnuclear imagingstudies including myocardial perfusion studies, brain SPECT imaging (includ-ingDATscan),In-111OctreotideandI-123MIBGscans and lymphoscintigra-phyareperformed.AmodernSPECT/CT(16slice)scannerandPET/CTscan-ner (16 slice) were installed at SEA.Therapy with radiopharmaceuticalsis routinely performed for hyperthy-roidism, thyroid cancer (using Iodine131) and bone pain palliation (usingStrontium89andSamarium153).Ra-

dioimmunotherapy (with Yttrium 90Ibritumomab tiuxetan) for treatingnon-Hodgkins lymphoma and Ra-223dichloridetherapyformetastaticpros-tate cancer . VAPSHCS continues toprovideteleradiologyserviceforthein-terpretationofnuclearmedicinestud-ies performed at Spokane VA Hospital. Inaddition,DISsupportsanumberofcommittees and conferences dealingwith cancerpatientsat its SeattleDi-vision,includingTumorBoard,CancerCommittee,TumorRegistry,Gastroen-terology-Surgery Conference, Neurol-ogy/Neuro-Surgery Conference, Livertumor conference,GenitourinaryCon-ferenceandRadiationSafetyCommit-tee. In 2015, a total of 98,000 radio-logicexaminationswereperformedattheVAPSHCS.DiagnosticImagingalsoprovides consultation on studies per-formed at outside hospitals and telera-diologyservicesforotherVAhospitalsin VISN20.

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Urologic Oncology ProgramBruceMontgomery,MDandMichaelPorter,MD

The multidisciplinary Urologic Oncol-ogy program is designed to help pa-tientswithgenitourinarycancersofalltypes and give them the opportunityto discuss their therapeutic optionswith a broad range of care providerswho treat patients with this disease,includingurologists, radiationoncolo-gists, medical oncologists endocri-nologists, advanced registered nursepracticioners,specialtytrainednurses,and physical therapists. By providingthis type of integrated patient care,doctors hope to help patients makeinformed decisions and receive thebestpossibletreatment.Themultidis-ciplinaryteamofferssomeofthemostadvancedtreatmentoptionsavailablefor prostate cancer, including nervesparingprostatesurgery,brachythera-py(radiation implants),adjuvantche-motherapy, the latest options in hor-monaltherapy,andadvanceddiseasechemotherapy studies. The center is one of a select few VA centers in the country utilizing the DaVinci roboticsystem to perform prostatectomies. Wealsooffer cuttingedge treatment

optionsforkidneyandbladdercancer,includingroboticpartialnephrectomy,laparoscopic nephrectomy, energybased ablative techniques for smallrenaltumors,radicalcystectomywithurinary diversion for muscle invasivebladder cancer, and adjuvant thera-pies for non-muscle invasive bladdercancer including chemotherapy placed intothebladder.Finally,weoffercon-tinuing care of urologic cancer survi-vors which includes management oflong termsideeffectsofcancer ther-apyincludingerectiledysfunctionandurinary symptoms. We are a cancer re-ferral center for all of VISN 20 and also provide comprehensive care for can-cers that are more uncommon in the Veteran population, including testisandpeniscancer.TheProgramactivelyparticipates in cutting edge research,and offers ongoing trials in bladdercancer treatment and active surveil-lanceofprostatecancer.Forinforma-tion, contact the Oncology Depart-mentat(206)764-2709ortheUrologyDepartmentat(206)764-2265


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Gastroenterology and HepatologyJasonA.Dominitz,MD,MHS;HarithaAvula,MBBS;GeorgeIoannou,MD,MS

Cancers of the digestive system con-stituteasignificantportionofthecan-cers diagnosed and treated at the VA PugetSoundHealthCareSystem(VAP-SHCS).Increasedawarenessandcom-pliance with colorectal cancer screen-ing, aswell as the rising incidenceofhepatocellularcarcinoma,esophagealandpancreaticadenocarcinoma,haveresultedinever-increasingnumbersofprocedures performed for the screen-ing,surveillance,diagnosis,andtreat-ment of these cancers at our facility.

Procedures offered at the VAPSHCSinclude liver biopsy, esophagogastro-duodenoscopy (EGD), sigmoidoscopy,colonoscopy, capsule endoscopy, en-doscopic retrograde cholangiopan-

creatography (ERCP). Endoscopic ul-trasound (EUS) is also available toVeterans needing tissue acquisitionforthediagnosisofcancer,aswellasfor cancer staging. Other procedures include endoscopic palliation of ma-lignant obstruction (e.g. esophageal,duodenal, biliary or colonic obstruc-tion),inadditiontopercutaneousen-doscopic gastrostomy for nutritionalsupport.Therearenowninefull-timestaff gastroenterologists/hepatolo-gists, two nurse practitioners, and asuperbteamofnursesonstaffattheSeattleandAmericanLakecampuses.Gastroenterology and Hepatology providersparticipate inweeklymulti-disciplinary conferences for the man-agement ofmalignancies (e.g. Tumor

BoardandLiverTumorConference).

All staff physicians at the VAPSHCSholdfacultypositionsattheUniversityof Washington and the GI team usually includes fellows, residents andmedi-calstudentsfromtheUniversity.Mem-bersofourGISectionarealsoactivelyinvolved in investigation relevant tocancer,includingbasic(e.g.DNAmeth-ylation&carcinogenesis),translational(e.g.screeningtools),andclinical(e.g.screening, diagnostic and treatmentstrategies) research. They also col-laborate with the research programs of many other departments within the VAPSHCS,theFredHutchinsonCancerResearchCenterandtheUniversityofWashington.

NutritionandCancerAmandaKusske,MS,RDandStephanieCrabtree,MS,RD,CNSC

Nutritionisessentialincontributingtooptimal outcomes in patients under-going cancer treatment. Eatingwellduring cancer treatment can help pa-tients maintain strength and energy,decreasetheirriskofinfection,andre-ducethesideeffectsfromtreatment.Patientsundergoingcancertreatmentcanexperiencenumeroussideeffectsthat can adversely affect their abil-ity tomaintainpropernutrition:nau-sea, vomiting, early satiety, diarrhea,taste and/or smell changes, difficultywithswallowing,andlossofappetite.Weight loss can result from these side effectsandcanputpatientsathigherriskofhospitalization,andpotentiallydelay surgery.

Nutrition and Food Services at VAPuget Sound Health Care System pro-vides nutrition education and coun-seling by Registered Dietitians to Ra-diationOncology,CancerCareClinics,Marrow Transplant Unit patients andtheir caregivers on an individual andgroupbasis.Topicsofevidence-basededucation and counseling includeweightmanagement,foodsafety,can-cer reoccurrence prevention, basichealthy eating, Diabetes education,and symptom management. Many patientswillrequireafeedingtubetomaintainnutritionandhydrationdur-ing and after cancer treatment. Thedietitian provides tube feeding for-mula recommendations to patients

andproviders,providesinstructiononfeeding and hydration, utilizing feed-ingpumps,andmonitorstubefeedingtolerance and progression.

ManypatientsundergoingBoneMar-rowTransplantsmayrequiretotalpar-enteral nutrition (TPN) during theirtreatment. In this case, the dietitianprovides TPN recommendations andmonitors patients’ nutritional statusthroughout the transplant process. The dietitian in the bone marrowtransplantunitisnationallycertifiedinnutritionsupporttoensureallpatientson TPN are appropriately monitored based on the most recent research and recommendations. In addition,

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the dietitian provides guidance andpolicy oversight to the provision ofhighqualitypatientfoodservice.

Our Nutrition Support Team, (NST)continues to meet weekly to discusshighriskpatients,currentarticles,andtomake sure thatweare all utilizingthemostcurrentevidencedbasednu-trition practices. Our team includesseveral Clinical Dietitians, Doctorsfrom GI and Surgery, and a Pharma-cistasavailable.Wealsocontinuetowork closely with Pharmacy as we are enjoying the ability to customize ourTPNworkingtopreventcomplicationsassociatedwithoverorunderfeeding.This year, we established a Nutrition

Nutrition and Cancer (Continued)

Oncologyconsulttobettermanagethereferralofveteranstoourtwooutpa-tientnutritionclinicsforRadiationOn-cology and Cancer Care. This has been verybeneficialinhelpingtomeetthegrowingneedsofnutritioneducation,dietarycounseling,weightmonitoring,and nutrition support managementinthishighriskpopulation. WehavealsohadagreatlyanticipatedupdateonourVISN20OutpatientEnteralandOral Nutrition Supplement ProductsPolicy,whichallowsClinicalDietitiansto prescribe oral supplements for out-patients who meet specific malnu-trition or disease criteria or who areundergoingcertainpre-surgicalevalu-ationandpreparation.


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WholeHealth:providingpatient-centered,personalizedandintegrativecaretoVeterans with cancer.Dr.LeilaKozak,ClinicalChampionOPCC&CT,VAPSHCS

Whole Health is VA’s own model of patient-centered, personalized andintegrative care has been rollingout throughout VA facilities nation-ally since 2013. VAPSHCS hosted theWhole Health Clinical Course at Amer-ican Lake Division on January 2015,with more than 45 staff and leader-ship attending the course. Groupsformed through the course continueto work to advance implementationof patient-centered care at VAPSHCS.In addition, the monthly IntegrativeHealthgroupmeetinghasnow100+staffmembers and continue to grow.AmongIHattendeeswehaveWilliamCampbellMD, our Chief of Staff, andGary BayneMSN, our Director Nurs-ing, who have been instrumental insupportingWholeHealthatVAPSHCS.You can read more about VA’s Whole Health athttp://www.va.gov/PATIENT-CENTEREDCARE/about.asp.

AtthecoreofprovidingWholeHealthtoourVeteransandfamiliesistheon-site availability of integrative thera-pies–complementarymodalitiesthathavebeenshowntosupportsymptommanagement and enhance wellness. At VASCHCS, we have been workingdiligently to increase implementa-tion of the Personalized Health Plan-ning (PHP) as well as availability ofintegrative health modalities for allVeterans.AsanactivememberofthePuget Sound Patient-Centered CareBoard, theVISN 20 Patient and Fam-ily-Centered Committee and a Clini-calChampionfortheOfficeofPatientCentered Care and Cultural Transfor-

mation (OPCC&CT) at VACO, Iworklocally, regionally and nationally toadvance education in Whole Healthand promote implementation of andwideaccessto integrativehealthmo-dalitiesandWholeHealthpracticeap-proaches. Iamcommittedtoadvanc-ing Whole Health implementation atPugetSoundbysupportingtheexpan-sionofintegrativemodalitiescurrentlyavailablethroughcancerandpalliativecareservices.

AtPugetSound,Veteransalreadyhaveaccesstoavarietyofintegrativehealthclasses including mindfulness medita-tion,yogaandtaichi,aswellasothermodalities offered through PrimaryCare/Mental Health and Health Pro-motion and Disease Prevention. Cur-rent patient education opportunitiesare posted at regularly updated and posted at http://www.pugetsound.va.gov/monthview.asp?thisMonth=10&thisYear=2015.

Oneofthecurrentprogramswehaveavailable for cancer care at PugetSoundisthe“Touch,Caring&Cancer”(TCC) Program (www.partnersinheal-ing.net). TCC was originally tested atVAPSHCS in 2012-2013. Results fromthe study showed that the program helpeddecreasepain,anxietyandfa-tigueinVeteranswithcancer.Inaddi-tion, caregivers who learned to pro-vide massage benefited too, feelingmore confident about their ability tosupport their partner during cancer treatmentandreportinganincreasedsenseofclosenessintheirrelationship,

nurturedbythemassagepractice.Vet-eransandtheircaregiverswerehighlysatisfied with this program (Kozak etal,2013).ThankstoourOPCCfunding,VAPSHCS has received copies of thisaward-winningmultimedia program -

currentlyavailableforfreetoanyVet-eranandtheirspouse/caregiveratVAPuget Sound Cancer Care through On-cology Social Work.

Integrative Therapy Tool-Kits for Whole-Health ImplementationWe recently completed a series of implementation toolkits and educa-tional videos (available throughTMS)for Healing Touch, Touch Therapiesand Massage Therapy. This projectwas possible through a collaborationamong 20 VA hospitals and CLCs from 6differentVISNs,anddevelopedma-terials to support implementation ofintegrativehealthmodalitiesatPuget

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Sound as well as other VA facilitiesnationally.Wewererecentlyselectedto present our project at the 2015Planetree International Conference.Thisconference,thatwasattendedbymore than 800 hospital staff and ad-ministrators, highlights excellence inimproving the patient experience athospitals around the globe.

The videos developed showcase suc-cessful implementation of TouchTherapies and Massage Therapy at various facilitiesanddevelopedaba-sic massage training for VA staff. Animplementation toolkit with all theresources necessary to successfully implement Touch Therapies and Mas-sage Therapy at VA facilities is avail-able along with the video resources.TheImplementationToolkitwillbeup-loaded as a resource within the TMS courseaswellasavailablethroughtheHealth for Lifewebsite http://health-forlife.vacloud.us/.Videosinclude:- Touch Therapies and Massage

TherapyatVAFacilitiesvideo-web-based on demand TMS course with

1 hour CE credit. You can previewthis video at http://bcove.me/lin-1jpr8.

- Touch Therapies and MassageTherapyatVAFacilitiesvideo–a19minutevideoshowcasingthevoiceof Veterans, staff and leadershipfromfacilitiesthathavesuccessfullyimplemented touch therapies and massage therapies at the VA. You can preview this video at http://bcove.me/vw3jjotp.

- BasicMassageSkillsforTrainingVAStaff(Chapters1-8)-Thisseriesof8shortvideosandadescriptiveguideare intended to train VA clinical staffwhoareinterestedinincludingtouch therapies within their clinical encounters. The techniques weredemonstratedbyAllisonMitchinson,MPH LMT NCTMB, Massage Pro-gramSupervisorandLeadMassageTherapistatAnnArborVAMC,whohasbeenapioneer indevelopingalong-standing and successful touchtherapies/massagetherapyprogramatAnnArborVAsince2007.

Whole Health EducationWhole Health is VA’s own model of patient-centered care. Developedthrough partnerships with Planetree (www.planetree.org) and the Depart-ment of Integrative Medicine at theUniversity of Wisconsin/Madison,these national contracts have helpedshaped VA’s approach to deliveringVeteran-centered, personalized andintegrativecare.Whole Health focuses on:- Changing the conversation with



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Veterans and families from “What isthematterwithyou”to“Whatmatterstoyou?

- To “change the conversation,”we are using new tools that help clinicians develop a “Per-sonalized Health Plan” that iscentered on each Veteran’s personalvisionofhealth.

- The “Components Of Pro-Ac-tiveHealth&Well-Being”helpthe Veteran become aware of thedifferentareasthatmaybeaffecting their sense of healthandwell-beingandwheretheyfeel it is important to initiateaccording to their preferences andpriorities

Youwillfindmoredetailed infor-mationaboutthesetools,aswellas the Whole Health curriculum at http://healthforlife.vacloud.us/index.php/education/2015-01-06-16-30-49

Patient-centered care’s role in cancer carePatient-centered care (PCC) is carethatplacesthe“patientatthecenter”andconsidersthepatientasawhole–physical,psychological,socialandspir-itual being. PCC implies changing the wayweoffermedicalcarebyempha-sizingnotonlystateoftheartmedicalinterventionsbutalsoonprovidingthebest supportive environment that pro-motes healing. This is usually referred to asenhancingthe“patientexperience.”

The patient experience of care hasbeenshowntohaveagreatimpactonhealingoutcomes.Currently,hospitalsaround the country (VA and non-VA)considerthepatientexperienceanewspecialty and have developed a “Pa-tientExperienceOfficer”positionthatattendstoenhancingthepatientexpe-rienceathospitalfacilities.

The “patient experience” is nurturedbytwocoreprinciplesofPCC-HealingEnvironments and Healing Relation-ships aswell as by the integrationofintegrativehealthmodalities that en-hance wellness and provide psycho-social-spiritual support. Healing en-vironments and healing relationshipssupport cancer patients by providingthenurturingenvironmentwheretheyfeelseenaspeople,not justasadis-ease. - Healing Environments refers to

transforming the physical environ-ment of care in a nurturing, sup-portive space that is conduciveto healing. Healing environmentsarecreated through theuseofEv-idence-Based Architectural Designprinciples. “Evidence-Based De-sign” isafield thatemphasizes re-searchevidencetoguidethedesignof healthcare spaces indoors and outdoors.Studieshaveshownthatcertain architectural design fea-turescanimprovepatientandstaffwell-being, support healing, pro-

motestressreductionandenhancesafety. For example, designs thatincorporatenaturallight,colors,artinstallations and views of naturepromotehealingand improveout-comes in health care. The use of re-laxing music and aromatherapy has beenshownto improvemoodanddecrease stress/anxiety in patientsas well as employees. - Healing Relationships refersto creating relationships betweenpatients and providers and amongstaffthatreflecttrust,hope,anda“senseofbeingknown”(Scottetal,2008).Emotionalself-management(emotional intelligence) andmind-fulnessarecompetenciesthathavebeen found to be key facilitators in healing relationships. The WholeHealth curriculum provides re-sourcesforstafftoenhanceaware-nessofemotionalself-managementand mindfulness, so they maymodelthesetopatientsandinthatmanner,fosterhealingrelationshipswithin healthcare.

For Whole Health to take roots andprovide its full benefits, everyone in-volvedinthehealthcaresystemneedstohave the skills toprovide support-ive, patient-centered, holistic care. Awelcoming smile or a helping hand,atriumspacewithliveplantsoraviewofthemountains,aquietspacetoprayormeditate,everydetailaffectsapa-tient’sexperienceandcontributesdi-rectlytohis/herhealthandwell-being.To access the Whole Health curricu-lum, VA staff can visit http://health-forlife.vacloud.us/index.php/research-education/education/.

Why is Whole Health so relevant to cancer care?Integrative therapies have an impor-tantroleincancerandpalliativecare,

the Veteran become aware of

according to their preferences

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providing a wide range of benefits.Touch/Massage Therapies, HealingTouch, Yoga, Tai Chi and medita-tion are examples of evidence-basedcomplementary interventions widelyused in cancer care around the coun-try and abroad. Because of their evi-dence in decreasing pain and anxiety andimprovingqualityoflife,theyareincreasinglyofferedtocancerpatientsandtheirfamiliestoimprovesymptommanagement.

The Whole Health approach to care includes these modalities as part ofthe wellness strategies that need to be available for patients and fami-lies to support them through cancer treatment and palliative care. Othermodalities widely used that can beincorporated into cancer care include acupuncture, guided imagery, hypno-sis,musicandarttherapy,andanimal-assistedtherapies.Formore informa-tion on how other VA facilities haveembraced Whole Health (includingwithin cancer and palliative care ser-vices)please visit http://healthforlife.vacloud.us/index.php/research-edu-cation/education/

Theroleof integrativehealthmodali-tiesincancercarehasbeenrecognizedacross comprehensive cancer carecentersnationallyandinternationally.Astheevidenceforthetheuseofinte-grativetherapies incancercaregrew,top cancer care centers such as Memo-rialSloanKettering,MDAndersonandDana-FarberCancerCenterhavebeendeveloping on-site Integrative Oncol-ogyServicesforthelast10years.Withour official rolling out of the WholeHealthCurriculumatVAPSHCSinJanu-ary2015,ourfacilityisonestepfurtherin bringing integrative cancer care toour Puget Sound Veterans.

Now entering my 5th year as a Clini-cal Champion for OPCC, I look backandseetheamazingprogresswehavebeen doing at Puget Sound during the last4yearsaswellastheexcitingop-portunities ahead to continue the in-tegrationofWholeHealthintocancerandpalliativecare.

ReferencesKozak L, Vig E, Simmons C, EugenioE, CollingeW& ChapkoM. (2013) AFeasibility Study Of Caregiver-Provid-edMassageAsSupportiveCareInVACancer Patients. J. of Supportive On-cology,2013Aug[Epubaheadofprint].

Scott JG, Cohen D, Dicicco-Bloom B,Miller WL, Stange KC, Crabtree BF.Understanding healing relationshipsin primary care.Ann FamMed. 2008Jul-Aug;6(4):315-22. doi: 10.1370/afm.860. PubMed PMID: 18626031;PubMed Central PMCID:PMC2478496.

TouchCaring&CancerProgram,avail-able at http://partnersinhealing.net/index.htm A Guide to Integrative Oncology forClinicians and Patients, available athttp://depts.washington.edu/in-tegonc/clinicians/about.shtml

OfficeofPatient-CenteredCare&Cul-tureTransformationwebsite,availableathttp://healthforlife.vacloud.us/

OfficeofPatient-CenteredCare&Cul-ture Transformation SharePoint site,available at http://vaww.infoshare.va.gov/sites/OPCC/default.aspx

Whole Health curriculum may be ac-cessedat http://healthforlife.vacloud.us/index.php/research-education/education/


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CancerCareNavigationTeamAnaFisher,LICSWOSW-C,TamarindKeating,ARNP,LynsiSlind,RN,MN

TheCancerCareNavigationTeamisamultidisciplinaryteampartneringwithVeterans with cancer to identify andeliminatebarrierstocareandimproveoutcomes

Cancer patient navigation was devel-opedinthe1990sasamethodtoad-dress health disparities that impactcancer prevention, detection, diag-nosis, treatment and survival. Pov-erty, lack of insurance, distance froma treatment facility and other factors maybebarriersthatpreventpatientsfrom getting necessary and timelycare. By partnering with vulnerablepatient populations to identify andaddress these barriers, navigationprogramshavebeen able to improvescreening rates, timeliness of care,compliance, patient satisfaction andsurvival rates. These programs havebeen implemented in cancer centers acrossthecountryandpatientnaviga-tionisnowastandardofcareforpro-grams accredited by the Commission on Cancer.

VISN20 implemented a network of CancerCareNavigationTeams(CCNT)aspartofa3yearpilotprogramwithsites in Anchorage, Boise, Portland,White City (Oregon), Roseburg, Se-attle,Spokane,andWallaWalla.InSe-attle,ourCCNTincludesanursepracti-tioner,registerednurse,socialworkerand program support assistant.

A community needs assessment com-pletedin2014identifiedbarriersVet-erans encounterwhen receiving can-cer care at the VA Puget Sound Health CareSystem(VAPSHCS).Comparedtoan ambulatory population, Veteransreceiving care at a VA facility werethreetimes as likely to bediagnosed

with cancer and had higher rates of co-morbiditiesthatmayimpacttheircare.AtVAPSHCS,anaverageof1,160Vet-erans are diagnosed or treated for can-cer each year.Nearly half of patientstraveled >50 miles to receive cancercare. Travel was a significant sourceofdistressandaffectedthetimelinessofcare.Inalocalstudyreviewinglungcancerdiagnoses,themeantimefromsuspiciontodiagnosiswas48daysforVeteranslivingnearSeattleand76daysforthose livingnearSpokane.Cancersurvivorshipcareisanunmetneedas14%ofVeteransreceivingcareattheVAhaveahistoryof cancer. Schedul-ing appointments, distress, nutrition,health promotion and health literacywere also important themes.

From these findings, CCNT imple-mented case management for priority groupsidentifiedtobeathighriskforencountering barriers to care: Veter-answhotravel>100milesforcare,re-quiremulti-modalitytreatmentand/orhave significant psychosocial barriers

tocare.AfterenrollmenttoCCNT,weidentifypotentialbarrierstocareandsources of distress and create a plan to address these. For Veterans referredfromanotherVAfacility,ahistoryandphysical is completed to document and manage other health conditionsthat may be relevant during an ex-tended stay away from home. Veter-ans receive ongoing support throughtheir treatment and a written treat-mentsummaryattheend,document-ing theircancerdiagnosis, treatment,complicationsandfollow-upplan.Thisinformationissenttohomeprovidersviainterfacilityconsult.

In order to coordinate care for Veter-ansenrolledinCCNTservices,weeklychartreviewsareconductedandtele-phone rounds are held with naviga-tion teams at other VISN20 facilitiesin order to identify and proactivelyaddressbarrierstocareandhavepro-vided these services to 450 Veteranssince our program launch in late 2014. CCNT is also addressing barriers to

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cancer care for all Veterans through several quality im-provement initiatives.Theseincludeimprov-ing access to Nutri-tion services, expand-ing cancer distress screening, creating acancer support group at American Lake,developing a patientresourcelibrary,docu-mentingguidelinesforcancer care consults,and creating a cancersurvivorship clinic.CCNT also gave pre-sentations regardingour navigation pro-gram and the impact of travel distance tothe VA on distress at theannualAssociationofVAHematology/On-cology Conference this year.

Please send us a consult, stop byouroffice(6East–6C-107),oremail([email protected])toengageour team and share feedback, con-cerns,orresourcesCCNTcoulduseaswe grow our program to reduce barri-ers to cancer care.

Refer a Veteran to CCNTIftheyhaveacancerdiagnosisAND• Travel>100milesforcare• Requiremulti-modalitycareand/or• Havesignificantpsychosocialbarri-

ers to care

SubmitaconsulttoCancerCareNavi-gation Team in theCPRS consult menu or call:206-277-4593


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Oncology Social WorkAnaFisher,LICSW,OSW-C;MelindaWalker,LICSW;KimmyVan,LICSW

Whenpatients receivea cancerdiag-nosistheyhavemanyconcernsaboutwhatthediagnosismeans,whattoex-pect,detailsonmedicalcare,concernsfrom loved ones, finances, and sur-vival. Comprehending and organizingtheprovidedinformationcanprovokeanxiety and be overwhelming whileone is making important health care decisions. The role of the Oncology So-cialWorker(OSW)iscentraltohelpingpatients, caregivers and communitieswith detection, prevention, naviga-tionandsurvivalinarapidly-changingtreatment environment. OSWs areuniquelytrainedinaccessingresourc-es, recognizing disparities in care,communication,stressreduction,fam-ilysystems,advocacy,andcommunityresources,allowingtheOSWtoaffectpositivechangeinthelivesofVeteransand their families.

Specifically,OSWsstrive toobtainac-curate and up-to-date educationalinformation and other resources forpatients.Thehopeisthatbycontact-ing patients early in the process andproviding themwith verbal andwrit-tenmaterial, thepatientswill have abetter understanding of what to ex-pect during their treatment and will alsobebetterprepared tocope. So-cialworkershavebeenactiveinpubliceducation campaigns including work-shops for veterans, conducting train-ingforstaffandcommunitypartners,and public message boards to inform Veteransaboutcancerprevention,de-tectionandcare;aswellasVeterans’benefits and VA resources. The OSWalso presented a component on cul-tural competence and grief, loss andbereavement during the End-of-Life

Nursing Consortium in the Spring of2015andprovidededucationtocom-munityhospiceagenciesonpalliativecareandhospice servicesat theVA .OSWs were involved in participatedintheplanningoftheCancerPreven-tion, Awareness, and Healthy Livinghospital wide event on September24, 2015. Additionally, OSWs provideongoingeducationtosocialworkstu-dentsthroughtheUniversityofWash-ingtonSchoolofSocialWork(UWSSW)practicum program, which provideshands-onexperience to students andtoprovidetheUniversitywithinputre-garding Social Work in health care.

Support groups and educational of-ferings can be beneficial at all stagesof the cancer experience. At VA Puget Sound, Social Workers co-facilitate asupport group for patient caregiverswho receive stem cell transplants aswell as a general diagnosis support groupforcaregivers.SocialWork,withthe assistance of other departments,sponsors and organizes a day-longworkshopdevelopedforVeteransandtheir caregiverscalled“Heroesof theHeart,” which provides informationabout self-care, resources available,MedicareandMedicaidplanning,ad-vancecareplanning,andestateplan-ning. This workshop was held in March 2015. OSWs are also planning an on-goingSurvivorshippsycho-educationalgroupforpatientstoprovideinforma-tionandsupportregardingtheeffectsofcancerandtreatmentonemotions,work and family. Two new cancer sup-port groups are scheduled to start at American Lake site: Veterans Cancer Support group and a Caregiver Sup-port group in the Winter 2015.

Cancertreatmentmovespatientsintoa new awareness and self-image. Pa-tients and their loved ones may feelincapable of managing independently at home. OSWs are highly skilled at as-sessingpatients’andfamilies’resourc-esandreferringpatientstothelevelofcare appropriate for their current situ-ationandneeds,includingcommunityoutpatient programs, home healthcare, skilled nursing or assisted livingfacilities, or hospice/palliative care.OSW assisted in the implementationof the NCCN Distress Thermometer for Patientsandisaddressingthepsycho-social needs of the Veterans at their initial radiation oncology and cancercareclinicvisits.

OSWsparticipateasmembersof theinpatient consultation team in thepalliative and hospice care program.Socialworkers,alongwithotherstaffmembers,focusonthepatient’squal-ityoflifebyassistingwithend-of-lifeplanning, care resources and emo-tional support. Additionally, OSWsprovide the patient and loved oneswith grief and bereavement supportand referral to resources during this transition. Social workers partici-pateinend-of-lifeeducationforstaffmembersandeducation forcommu-nity partners about the VA hospice andpalliativecareprogram,survivorbenefits,andburialbenefits.

OSWsareessentialinAdvanceCareDi-rective(ACD)planning,educationandcompletion.Socialworkersparticipateinahospital-wideinitiativetoimproveVeterans’ and staff members’ under-standingoflivingwills,durablepowerofattorney,andtheroleofsurrogate

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decision makers. Veterans are encour-aged to complete health care direc-tives to ensure their ongoing partici-pationintheirownhealthcareandtorelieve stress for lovedoneswhoarenamed as surrogate decision makers.

During the next year, OSWs at VAPugetSoundwillcontinuetoadvocateforVeteransinourcare,reducingbar-riers to care and increasing access to treatment whether through locatingappropriate transportation resourcesor finding financial resources to al-low them to keep their appointments. Social workers conduct quality train-ing forveterans,caregivers,staff,andcommunitymembersandwill contin-ue to train student interns at VA Puget

Sound. Social Work will continue tohold trainings at community hospitals and institutions of higher educationto increase awareness of Veterans’ benefits,programsanduniquehealthcare needs. With renewed emphasis on survivorship, there are is now acancersurvivorshipclinicatVAPugetSound.OSWswillcontinuetoworkonthecommitteeto improvethecancersurvivorship resources and pass thatinformation to Veterans and medicalprofessionals at the hospital. We will continuetoprovidecaregiverandVet-eran education and support groups.Theseeffortssupporttheoverallgoaltohelppatientsmaintaintheirqualityoflifewhiletheycopewithvariousis-sues that arise during cancer care.


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CancerRehabilitation/ RehabilitationCareServiceMegSablinsky,PT,DPT,CLT–LANA

Forpatientsundergoing cancer treat-ment,qualityoflifemattersasmuch—ifnotmore—thanthequantityoflife.With an increasing focus on rehabili-tation, patients are able to have im-proved quality of life during and af-ter their cancer treatment. Patientsundergoing cancer treatment may experience one or more of the fol-lowingsideeffects:decreasedmusclestrength,decreasedbonedensity,pe-ripheral neuropathy related to chemo-therapy, fatigue, decreased range ofmotion, pain, lymphedema, and scaradhesion.RehabilitationCareServicescanassistpatientswhohavebeendi-agnosedwithcancerwithavarietyoftheir rehab needs on an inpatient oroutpatientbasis.Theseneedsincludepain control, weakness and decon-ditioning, mobility including assess-mentandprovisionofequipment formobilitysafety,activitiesofdailylivingsuch as dressing/grooming/bathing,cognition, communication, swallow-ing, nutrition, bowel/bladder func-tions, skin integrity andwoundman-agement, lymphedemamanagement,depression/adjustment/anxiety, socialsupport, and vocational guidance.Goals for cancer rehabilitation oftenincludeeffectivepaincontrol,maximalfunctional independence, restorationofmaximalstrengthandmobility,pre-vention of further impairment, care-givertrainingtoassistfunctionally-de-pendentpatients,homemanagement,community reintegration, and behav-ioraladaptationtopainandillness.

In addition, a specialized service thatRehabilitation Care Services offers is

CompleteDecongestiveTherapy(CDT),a treatment for lymphedema. Lymph-edemaisswellingofabodypart,mostcommonly involving the extremities,face and neck but it may also occur in thetrunk,abdomenorgenitalarea.Itis most commonly the result of damage tothelymphaticsystemduetosurgeryor radiation treatment therapy, surgi-cal procedures performed in combina-tionwiththeremovaloflymphnodessuchasmastectomies,lumpectomies,prostatectomies, or neck dissectionprocedures,traumaorinfectionofthelymphatic system, as well as severevenous insufficiency.There isnocurefor lymphedema. However, CDT canhelp reduce the swelling and maintain reduction,andsignificantlyimproveapatient’s quality of life. This compre-hensivetreatmentinvolvesthefollow-ing four steps:• manual lymph drainage• compressiontherapy(bandaging)• decongestiveexercises• skin care

Once the treated extremity/area isback to close to normal size or is nolonger reducing in size, thepatient isfittedwithacompressiongarment.Pa-tientsarealsotaughthowtoselfman-agetheirconditionaftertreatmenthasended.Attheendof6-8weeksofses-sions,wecanexpecta60%decreaseintheswelling,whichfacilitatesfunc-tional activities for these patients. Inaddition, the lymphedema treatmentprogram for head and neck patientswillhelpthemrecovertheirabilitytoswallowandproducesaliva,voice,andROM of the neck.

Duringthis2015year,ourLymphede-maClinichasatotalofsevencertifiedtherapists: Brian Reaksecker, PT CLT,Mary Matthews-Brownell, OTR-L CLT,MaureenMclain,PTCLTatALVA,andinSeattlewehaveErinHirschler,OTR-L CLT, Meg Sablinsky, PT CLT-LANA,Melissa Smith, PTA CLT, and JenniferBoyce,OTR-L,CLT.

We also have developed a Head andNeck Lymphedema Management Pro-gram and we are working closely with Radonc and Surgery to see these pa-tientsasearlyaspossible.Sometimesitwillbeonlyforafewsessions,evalu-ating,educatingaboutwarning signs,decongestive exercises, range ofmo-tionexercises,posture,or sometimesmanuallymphaticdrainagewhennec-essary.Wearealso trying todeveloppost-surgery education handouts, inconjunctionwithSurgery.

We also have an increasing number ofearly consults for patients with breastcancer, which is quite successful sincemost of the time they haven’t devel-oppedlymphedemayetoritisataveryearlystage.Thesepatientsreceiveeduca-tion regardingwarning signs, deconges-tiveexercises,activitiesofdailylife,man-ual lymphatic drainagewhen indicated,andsometimestheywillbefittedwithanappropriate compression garment.

In all the cases of oncology patients,notonlydotheygetbetterwithtreat-ment,buttheyalsofeelsomewhatre-assured and feel support which is also very important.Theirqualityof life ismuchimproved.

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PalliativeCareandHospiceServiceReportLisaVigMDandDavidAGruenewaldMD

The Palliative Care and Hospice Ser-vice(PCHS)continuestoprovidecareforpatientsonbothcampusesofVAP-SHCS. ThePalliativeCare Service saw676 consults in FY15 (a15% increasefromFY14).Outof373inpatientpal-liative care consultations in FY 2015,164or44%werecancerpatients.Pal-liativeCare saw91%ofall theVeter-answhodiedwithin our facility,wellexceeding the Emerging Measure 3standard (55%of all inpatient deathsseenbytheconsultationteamwithin12 months prior to death). We alsoprovidedhospicereferralsto422Vet-eransandpaidfor66%ofthehospicecareprovidedunderthesereferrals.

The consult service follows VeteransatboththeSeattle(SEA)andatAmeri-canLake(AL)divisions.Thereareupto10hospice/palliativecarebeds intheSEA Community Living Center (CLC)and12bedsatALCLC.Outpatientpal-liativecareservicesarenowavailableatbothSEAandAL,aswellaslimitedhomevisits/in-homevestingvisitsinadefined area around the AL campus.Outpatient palliative care visits areup74%inFY2015(303consultations)compared to FY 2014 (174 consulta-tions), reflecting an increase in bothface-to-face visits and non-visit con-sultations(recordreviews).

The PCHS continues to engage ac-tively with our community partnersin the We Honor Veterans program,sponsored by the Department of Vet-erans Affair in collaborationwith theNational Hospice and Palliative CareOrganization (NHPCO). The program

inviteshospicesandstatehospiceor-ganizationsintoHospice-VeteranPart-nerships by recognizing the uniqueneeds of America’s Veterans and their families.ThePalliativeCare&Hospicestaff has provided in-services at indi-vidualcommunityhospices.AMilitaryHistory Checklist has been incorporat-ed intomany hospices’ initial assess-ments,whichhasincreasedcallstothePCHS as hospice programs seek ways to access VA benefits for Veterans inthe community. Members of our pal-liativecareteamhavemetwithrepre-sentatives of our community hospicepartnerstodialogueabouttheservic-esVA canoffer toVeterans receivinghospicecareinthecommunity,andtoanswerlogisticalquestionsabouthowtoarrangefortheseservices.

TheBereavedFamilySurvey(BFS)isanationalVA family satisfaction surveyadministered by the PROMISE Center that continues to monitor the qual-ityofendoflifecareforinpatientsatall VA medical centers. The nationalcampaign slogan is “Strive for 65”,which refers to the goal that 65% ofbereaved family members respond-ing to the BFS will rate the overallcare theVeteran received at the endoflifeas“excellent”.Ourfacility’sper-formance on this indicator dropped from60% in FY14 to54% (below thenationalaverageof61%)inthefirst3quarters of FY14. Examining the an-swer breakout for the BFS, a notablechange from FY14was a decrease insatisfaction with emotional supportprovidedprior toandafterthedeathofalovedone.Weareevaluatingthe



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specificcommentsoffamilymembersaswellasthedatabyvenueofcare,todeterminewhatkindsofinterventionsmight be indicated. We are also moni-toring BFS data to identify whetherthis is a longer term trend.

Palliative care is continuing to col-laborate with our ICUs to improvepalliativecareintheICU,withafocuson improving the quality and timeli-nessoffamilymeetings.Astakeholderworkgroupmeets every 2weeks andthe workgroup reports progress to the Critical Care Committee. The work-group is currently refining the familymeetingnotetemplatethatiscurrent-lyinuse.Theexistingtemplateallowsthecollectionofhealthfactorstotrackqualitymeasuresforfamilymeetings,including which disciplines were rep-resented, the code status of theVet-

eranbeforeandafterthemeeting,andgoalsofcareattheendofthemeeting.Additionalmodificationswillbringthetemplate in linewith published qual-ity indicators for family meetings. Inthe coming months we are planning to conducta4hourpalliativecareeduca-tionalsessionforICUnurses.Asnotedinlastyear’sreport,thelongtermgoalis to encourage these discussions to happen earlier in the course of care,which could result in fewer Veterans with cancerandother life-limiting ill-nesses receiving unwanted and inap-propriate ICU-level interventions attheendoftheirlives.Wehavefoundthat a surprising number of patientswith terminal cancer are dying in the ICU.InasurveyofICUdeathsinQ3ofFY2013,17of27ICUdeathsoccurredinpatientswithterminalillnessessuchasmetastaticcanceratthetimeofICU

Palliative Care and Hospice Service Report (Continued)

admission (Dr. Vincent Fan, personalcommunication).Thispresentsanop-portunity for collaboration betweenOncology,ICUandPalliativeCare.

Withthis inmind, thePCHS isseeingpatientsintheCancerCareClinicandin Radiation Oncology who are iden-tified by their Oncology providers asbeing appropriate candidates for pal-liativecareinvolvement(e.g.,forgoalsofcarediscussions,symptommanage-mentsupport,familysupport,orotherneeds). Asnotedabove,thenumberofoutpatientpalliativecareconsulta-tions has increased markedly in thepastyear,withmanyoftheseconsul-tationsbeingforVeteranswithcancer.WecontinuetoworkwiththeCancerCareNavigationTeamto improvethecoordination of Veterans requiringCancer Care.

Pulmonary MedicineRichardB.Goodman,M.D.;DavidH.Au,M.D.;TiffanyM.Bridges,M.D.

Lung cancer is one of the most com-mon solid tumors and the leading cause of cancer mortality in our na-tion’s veterans. Prevention and diag-nosis of lung cancer is a cornerstone of Pulmonary Medicine at the VA Puget SoundHealthCareSystem.Weevalu-ate a breadth of cases from inciden-tallydiscoveredpulmonaryabnormali-tiestohighlysuspiciouslesionsinthemost at risk individuals with severeunderlying pulmonary diseases such asCOPDor IPF.PulmonaryMedicinemaintains integral relationships withDiagnostic Radiology, Thoracic Sur-gery, Radiation Oncology, andMedi-calOncologyinordertoexpeditiouslydiagnose and support our veterans’optimaltherapeuticoptions.

Pulmonary diagnostic services in-clude fiberoptic bronchoscopy withbronchoalveolar lavage (BAL) for cy-tology and microbiologic assessment of concomitant infection, brush cy-tology, as well as endobronchial andtransbronchial biopsies (TBBX) to aidin thehistologicdiagnosisofpatientswith suspected lung cancer. With our recent acquisition of endobronchialultrasound (EBUS) for transbronchi-al needle aspiration (TBNA), we areon the verge of expanding our pre-surgical mediastinal staging capabili-ties and enhancing multidisciplinarycare with Thoracic Surgery. We can perform thoracentesis for diagnosticanalysis of pleural effusions and pro-vide symptomatic relief for patients

who suffer from malignant pleuralfluid reaccumulation. The PulmonaryFunction Laboratory (PFT) providesmeasurements of lung function thatare invaluable in planning therapeu-tic interventions.WeperformCardio-pulmonary Exercise Testing (CPET) asanon-invasivetechniquetoquantitatecardiopulmonaryreserveandaidintheaccurate assessment of cardiovascularcomorbiditiesandriskofpostoperativecomplicationsoflungcancerresection.

Manyofourveteranswithlungcancer,diagnosed at any stage and undergoing anytreatmentmodality,haveunderly-ingpulmonarydisease,suchasCOPD,and their care can require continuedsupport from Pulmonary Medicine,

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Spiritual CareChaplainGaryK.Cowden,BCCandChiefofChaplainService

Respiratory Therapy, and the HomeOxygen Program. The Pulmonary Re-habilitation Program at VAPSHCS is ajointventurewithRehabMedicine.In2015, PulmonaryMedicine expandedclinics to American Lake in order to provide VAPSHCS veterans with im-provedaccesstopulmonaryspecialtycare.Finally,wealsoprovideconsulta-tionthroughtheSpecialtyCareAccessNetwork- Extension for CommunityHealthcare Outcomes (SCAN-ECHO)and are therefore reaching even our

most rural veterans with potentiallungmalignanciesandtheirproviders. Pulmonary Medicine supports two na-tionallyrecognizedinvestigatorsstudy-ingqualityoflungcancercare.Togetherwith Medical Oncology and Thoracic Surgery, Pulmonary Medicine partici-pates in the multidisciplinary teamstudyingqualityandtimelinessofcarein lung cancer patients as part of theOQPprocesstoreducewait-times.

TheChaplainServiceof theVAPugetSound Health Care System has been given the overall spiritual care of allVApatients.AmongourVeteransarethose that experience the diagnosis andtreatmentofcancer. Atthetimeofapatient’sdiagnosisandtreatmentprojection, Chaplaincy endeavors tosupport the patient and their fam-ily as theyprogress through the vari-oustreatments,whetherit issurgery,chemotherapy,radiation,orastemcelltransplant. Spiritual support coversboththenegativeandpositiveaspectsofcancercaresuchastimesofwellnessandtimesofpalliativeintervention.

Chaplainsareavailablewiththetreat-mentteamsasvariousspiritualneedssurface in the treatment process. Of-ten,alongwiththeconcernsoftreat-ment symptoms, comes uncertainty,anxiety, fear of treatment outcomes,guilt, and spiritual distress. Throughconsultsandvariouspatientcontacts,chaplainsgivespiritualsupportaffect-ingpatientandfamilymorale. Chap-

lains have also been involved in theTele-healthprogramwhichbringscaretopatientsintheirhome.

One aspect of care involves timeswhentreatmentoptionsbecome lim-ited.PalliativeCarechaplaincyaffordsopportunity to bring meaning and pur-pose to these times to help patientsand their families transition to a dif-ferentperspectiveontheir treatmentgoals.Chaplainshavegivenconsistentandpositivesupportthroughthispro-cess.Whenthelimitationsofscienceleadapatienttowardanotherdestiny,Chaplains are prepared to give spiri-tualsupportthroughtheseun-chartedexperiences to both the patient andthe families surrounding them.

Finally, Chaplains bring bereavementcare to patients and families in thejourneyoffinishing theirtimeof life.Memorial services are held twice ayear for all patients who have beenin the hospital at their end of life. Theirfamiliesare invitedtoattendas

awayof celebrating theirmemory.Each family is invited toattendandto bring pictures and memorabilia that helps share their memory with others. The Hospital Director and variousstaffmembersareinvitedtosharetheexperience.Familymem-bersareinvitedtosharetheirlovedones experience. Many of the sto-ries of support by the VA Hospital giveoverwhelmingcredibilitytotheCancer program .

Pulmonary Medicine (Continued)

C a n c e r P r o g r a m A n n u a l R e p o r tC a n c e r P r o g r a m A n n u a l R e p o r t

1660S.ColumbianWaySeattle,WA98108Phone:206.764.2934Fax:206.764.2851

CREDITS

EditingConsultants

Sudarshana DasAlisa Engeland

Graphic Design

Alisa Engeland

ArticleContributors(inorderofarticles)

PeterC.Wu,MD(CancerCommitteeChair)SudarshanaDas,B.Com,CTR,RHITVictoriaCampa,TumorBoardCoordinatorJeannineBartonandStephanieMagone, Oncology Clinical Trial CoordinatorDanielY.Wu,MD,PhDThomasR.Chauncey,MD,PhDMarcD.Coltrera,MDandJeffreyJ.Houlton,MDTonyS.Quang,MD,JD,AdamTazi,PhD, andKentE.Wallner,MDTamarindKeating,ARNP,MPHJosephGRajendran,MD,andJulieTakasugi,MDMichaelP.Porter,MDandBruceMontgomery,MDJasonA.Dominitz,MD,MHS,HarithaAvula,MBBS,GeorgeIoannou,MD,MSAmandaKusske,MS,RDand StephanieCrabtree,RD,CNSCLeilaKozak,PhDLynsiSlind,RN,MN,AnaFisher,LICSWOSW-C, andTamarindKeating,ARNPAnaFisher,LICSW,OSW-C,Melindawalker,LICSW, andKimmyVan,LICSWMicheleMeconi,ARNP,CDEMargaretSablinsky,PT,DPT,CLT-LANADavidA.Grunewald,MD,andLisaVig,MDRichardB.Goodman,MD,DavidH.Au,MD, andTiffanyM.Bridges,MDGaryK.Cowden,BCC,Chaplain

Documents

VA Puget Sound Health Care System Cancer Program 2015 Annual