cancer program annual report · 2018-05-03 · cancer program annual report 3 cancer registry...

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- CancerCommittee- TumorBoardActivities- Oncology Clinical Trials - Hospital &Specialty Medical Care

–OncologyDivision- Marrow Transplant Unit- Head&NeckCancerService

Oncology Clinical Trials- RadiationOncology-Continuous

QualityImprovementasaPillarforQuality,Safety,andPatientCentered Care

- Special Study Report on monitor-ingcompliancewithevidencebasedguidelines-Neo-adjuvantChemotherapyformuscleinva-siveBladderCancerattheVAPuget Sound Health Care System: aGuidelinebasedMultidisci-plinary Approach

- DiagnosticImagingServices- Thoracic Surgery- Surgical Oncology- Urologic Oncology Program- Telemedicine Program- Psychology – Whole Health - NutritionandCancer- OralMucositisCarePoster- CancerCareNavigation- Oncology Social Work- CancerScreeningandPrevention

Report- CancerRehabilitation/Rehabilita-

tionCareService- PalliativeCareandHospiceService- EnhancingCancerCareservices

through Whole Health- Spiritual Care

- Credits

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

Themission of the VA Puget SoundCancer Care Program is to provideexcellent and compassionate care to our Veteran patients diagnosedwith cancer. With a 2013 reported caseload of over 1,000 cancerpatients, our center continues torankamongthemostcomprehensiveandbusiestVAcancercentersintheUnited States. There were several noteworthyeventsthispastyear.Dr.DanielWu,M.D., Ph.D. was appointed Chief of Oncology following the celebrated retirement of Dr.William Schubach,M.D., Ph.D. A new state-of-the-art outpatient Cancer Care Clinic wascompleted which has increased capacity to 16 infusion chairs and providesveteransacomfortableandsupportiveenvironment.TheVISN20CancerCarePlatformInitiativeprovidedthenecessaryfundingtocreateourCancerCareNavigatorTeam(CCNT)ledbyTamarindKeating,ARNPwhowasrecruitedfromtheFredHutchinsonCancerResearchCenter.TheCCNTwillhelppatientsandtheirfamilies“navigate”theircancer journey with coordination of care and community resources, patientadvocacy,cancersurvivorshipandpsychosocialsupportservices.TheVAPugetSoundandDurhamVAcancerprogramssharethedistinctionasthe2nationalsites selected to pilot a new online chemotherapy management system designed toenhanceoutpatient clinicefficiencyand increasepatient safety. This long-awaitedprogramisscheduledforactivationinearly2015.

The 2014 Annual Report highlights the wide-range of services and clinicaltrialsofferedwithin theVAPuget SoundCancerProgramand recognizes theimportantcontributionsfromallservicelinesanddepartments.WethankourlocalandregionalVAleadershipfortheircontinuedsupportoftheCancerCareProgramandcontinuetostrivetoprovidethehighestqualitycancercareforournation’sveterans.

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Cancer Registry Report(basedonlastcompleteyear2013data)Sudarshana Das, COC Cancer Program Manager & Cancer Registrar

(Continued on next page)

Every yearmultitudeofdataonna-tionalcancerburdenispublishedbyCDC, SEER, American Cancer Society to name a few of the many other or-ganizations.Everthoughtwherethisdatacomesfrom?Allcancerstatisticsstemsfromgrass-rootlevelcollectionof cancer data at local hospital cancer registriesbyspeciallytrainedstaffs.

Cancerdatacollectionandreportingismandatedbyvariousstatutoryactslike the National Cancer Act 1971,Cancer Registries Amendment Act 1992etc.

A cancer registry collects and accu-rately records the clinical journey of a cancerpatient starting fromdiagno-sis including the process and meth-ods of, to treatment received, bothcurativeandpalliative.Acancerreg-istry conducts life-long follow-up of cancerpatientstilldeath,andstrivesto keep on collecting vital informa-tion longafter thepatienthasbeendischarged and/or cured to enablesurvivalandoutcomerelatedstudiesand research.

Thecollecteddataisavitalcontribu-tor to cancer research and outcomes measurement,andaninvaluabletoolin the fight against cancer. CancerRegistry Data is useful for analyzingpatternsof careandqualityof care,evaluating the effectiveness of cur-rent treatment modalities, develop-ing educational programs, early de-tection/screening cancer programs,and can help leadership in making in-formed decisions for hospital expan-sion, resource allocation and otherbusiness purposes.

Keeping in mind the importance of the accuracy of registry data, the Commission on Cancer (CoC) hasmadeitmandatoryaccreditationre-quirement that cancer registry cas-es are abstracted only by certifiedtumor registrars (CTR) who cancerdataspecialistsarehavingtheneed-ed education, expertise and certifi-cationrequiredforproperexecutionof the job.

VAPSHCS Cancer Registry

TheVAPSHCSCancerRegistryisman-aged by a facility employed cancer programmanager/CTR and thebulkof registry work is contracted out to qualifiedvendorchosenbytheVISN-20ContractingOffice.BestPracticesGroupisourcurrentvendorforcan-cer registry work.

The Registry regularly submits data on its analytic cancer caseload tovariousnationaldatabases,includingVACentral Cancer Registry (VACCR),CommissiononCancer-NationalCan-cer Data Base (CoC-NCDB), CancerSurveillanceSystem(CSS-SEERregis-try)forWAStatereportingpurposes.In addition, it participates and pro-vides data for special studies con-ducted at our facility, or at nationallevelforpatientcarequalityimprove-mentstudies,and forallothervalidpurposesasrequested.

Alldatasubmittedareaggregate,andpatient identifiers and protected in-formation are removed during datasubmission.


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Cancer Registry Report (Continued)

VAPSHCS Cancer Registry Data

TheVAPSHCSRegistryhascompiledarich data-base comprising of diagno-ses, staging, treatment, and outcome related information on over 15,000cancer cases accessioned at our facili-tytilldatesince1998,whichwaswhenour registry was formed, also known asthe“registryreferencedate”.

Some examples of the usefulness of cancer registry data can be seen in the data and graphs below:

In 2013, 865 analytic cases of can-cer,and235non-analytic cases, fora total of 1100 cancer cases were accessioned into the cancer registry database.

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Thetoprankingcancerprimarysite/systems seen at our facility in 2013 wereMale-Genital(Prostate),GIsys-tem , Respiratory system, Hematopoi-

etic&Lymphomas,Urinary system ,Head-Neck System, andMelanoma/reportable skin (non-reproductiveskin).



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Glossary of Terms:Abstract: a summary or abbreviated record that identifies, a cancer patient’s disease process from time of diagnosis till patient’s death including diagnosis, staging, cancer treatment. This forms the basis of a cancer registry.

Accession: to enter a reportable cancer case following national rules and guidelines into the registry database.

Analytic: Cancer patients diagnosed and/or received first course of treatment at VAPSHCS.

American College of Surgeons (ACoS): a professional organization of surgeons and physicians founded in 1913, which has supported standards for hospitals, formation of registries, and accredits quality cancer programs nationwide through its Commission on Cancer (CoC) accreditation.

Caseload: the number of new cancer cases annually entered into a registryCDC: Centers for Disease Control and Prevention is a federal agency of the Department of Health and Human Services.

Certified Tumor Registrar (CTR): the credentials granted to a person who has passed the cancer registry certification examination by the NCRA, and signifies specialized knowledge and education for accurate collection, recording and analysis of cancer data into registry databases.

Commission on Cancer (CoC): a division of the ACoS, consisting of over professional organizations involved in cancer control and improving survival and quality of life for cancer patients through standard-setting, prevention, research, education, and monitoring of comprehensive quality care. CoC accredited cancer programs, such as VA Puget Sound Health Care

System, signifies establishment of performance measures for provision of high-quality cancer care and is nationally recognized by JC (formerly JCAHO), ACS, CMS, NQF, NCI, to name a few.

CSS: Cancer Surveillance System collects population-based data on cancer incidence and survival in 13 counties in western Washington State, and is part of the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI).

DUA: Data Use Agreement, as required by VA national policies for sharing of data.

First Course of Treatment: Cancer directed treatment planned and administered, usually started within four months of diagnosis or as determined by the managing physician.

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PRIMARY SITE: FEMALE

TOT# ANALNON ANA Wh B Oth W B Oth

Sys:H&NexclLarynxLIP 2 1 1 2 0 0 0 0 0TONGUE, BASE 10 9 1 7 0 0 0 3 0TONGUE,OTHER/NOS 5 5 0 4 0 0 0 1 0GUM 0 0 0 0 0 0 0 0 0FLOOROFMOUTH 3 3 0 2 0 0 0 1 0PALATE 1 1 0 1 0 0 0 0 0OTHER/NOSMOUTH 2 2 0 2 0 0 0 0 0PAROTIDGLAND 3 3 0 2 0 0 0 1 0MAJORSALIVARYGL 0 0 0 0 0 0 0 0 0TONSIL 8 8 0 4 0 0 0 4 0OROPHARYNX 5 5 0 4 0 0 0 1 0NASOPHARYNX 1 1 0 1 0 0 0 0 0SUBTOTAL 40 38 2 29 0 0 0 11 0Sys:Gastro-Intestinal TOT# ANAL NON Wh Bl Oth W B Oth

ESOPHAGUS 21 21 16 1 4STOMACH 17 15 2 10 4 3SMALLINTESTINE 4 3 1 3 1COLON 45 39 6 33 4 3 5RECTOSIGMOID JUNC 5 5 5RECTUM 28 28 19 2 7ANUS/ANALCANAL 3 2 1 3LIVER/INTRAHEPATICBIL 28 28 21 3 4GALLBLADDER 4 2 2 1 2 1BILARYTRACTOTHER 3 3 3PANCREAS 21 20 1 16 1 4OTHER-DIGESTIVE 1 1 1SUBTOTAL 180 166 14 130 4 14 0 31 1Sys:Respiratory(+Larynx) TOT# ANAL NON Wh Bl Oth W B Oth

NASALCAV,MIDDLEEAR 2 2 2ACCESS SINUSES 1 1 1LARYNX 18 16 2 15 1 2LUNG/BRONCHUS 140 131 9 125 4 11THYMUS 1 1 1SUBTOTAL 162 151 11 143 0 5 0 14 0Sys:Bones,Joints,Articul TOT# ANAL NON Wh Bl Oth W B Oth

BONES/JOINTS/ARTICULAR 3 2 1 2 1SUBTOTAL 3 2 1 2 0 0 0 1 0Sys:Hematopoetic, Reti TOT# ANAL NON Wh Bl Oth W B Oth

HEMATOPOIETIC/RETICULO 76 58 18 56 4 6 2 8SUBTOTAL 76 58 18 56 4 6 2 8 0Sys:LymphNodes TOT# ANAL NON Wh Bl Oth W B Oth

LYMPHNODES 44 27 17 34 2 3 5SUBTOTAL 44 27 17 34 2 3 0 5 0Sys:Skin(exclreproductive) TOT# ANAL NON Wh Bl Oth W B Oth

SKIN 74 66 8 50 2 22SUBTOTAL 74 66 8 50 2 0 0 22 0Sys:Retreperitoneum&Per TOT# ANAL NON Wh Bl Oth W B Oth

RETROPERITONEUM & PERI 1 1 1SUBTOTAL 1 1 0 1 0 0 0 0 0Sys:Connective/SubQ TOT# ANAL NON Wh Bl Oth W B Oth

CONNECTIVE/SUBCUTANEOU 6 5 1 3 1 2SUBTOTAL 6 5 1 3 0 1 0 2 0Sys:Breast(exclskin) TOT# ANAL NON Wh Bl Oth W B Oth

BREAST 20 16 4 16 3 1SUBTOTAL 20 16 4 0 16 0 3 0 1Sys:Female Genital TOT# ANAL NON Wh Bl Oth W B Oth

CORPUS UTERI 1 1 1OVARY 1 1 1SUBTOTAL 2 2 0 0 2 0 0 0 0Sys: Male Genital TOT# ANAL NON Wh Bl Oth W B Oth

PENIS 1 1 1PROSTATEGLAND 250 195 55 182 35 33TESTIS 6 5 1 4 1 1SUBTOTAL 257 201 56 187 0 36 0 34 0Sys:Urinary TOT# ANAL NON Wh Bl Oth W B Oth

KIDNEY 34 30 4 24 8 2RENALPELVIS 1 1 1URETER 1 1 1BLADDER 48 47 1 37 2 4 5URINARYORGANS-OTHER/N 2 2 2SUBTOTAL 86 80 6 65 2 12 0 7 0Sys:Eye&CentralNerv TOT# ANAL NON Wh Bl Oth W B Oth

EYE/ADNEXA 3 3 1 1 1MENINGES 5 4 1 4 1BRAIN 14 12 2 11 1 1 1SPCORD,CRANIALNERVES 1 1 1SUBTOTAL 23 20 3 17 2 1 0 3 0Sys: Thyroid TOT# ANAL NON Wh Bl Oth W B Oth

THYROIDGLAND 17 15 2 12 2 1 2OTHERENDOCRINEGLANDS 2 2 2SUBTOTAL 19 17 2 14 2 1 0 2 0Sys:Other i l l-defined TOT# ANAL NON Wh Bl Oth W B Oth

OTHERILL-DEFINEDSITE 2 2 1 1SUBTOTAL 2 0 2 1 0 0 0 1 0Sys: Unknown TOT# ANAL NON Wh Bl Oth W B Oth

UNKNOWNPRIMARYSITE 11 10 1 10 1SUBTOTAL 11 10 1 10 0 1 0 0 0

TOTAL 1006 860 146 742 36 80 5 141 2

CASELOAD MALERACE RACE


NCDB: National Cancer Database is a nationwide oncology outcomes database for more than 1,400 CoC-approved cancer programs in the United States and Puerto Rico. Approximately 75 percent of all newly diagnosed cases of cancer in the United States are captured at the institutional level and reported to the NCDB.

NCRA: National Cancer Registrars Association is a not-for-profit association with a primary focus of education and certification, representing Cancer Registry professionals and Certified Tumor Registrars (CTRs).

SEER: a federally funded consortium of population-based cancer registries, established by the National Cancer Act if 1971 to collect and publish information on cancer incidence, mortality, survival and trends over time in the US.

References:1. VHA Privacy and Release

of Information 2006, VHA Handbook 1605.1, http://ww1.va.gov/vhapublications

2. VA Central Office Cancer Program, http://www1.va.gov/cancer/

3. Commission on Cancer Cancer/National Cancer Data Base: http://www.facs.org/cancer/

4. Previous Annual Reports5. Cancer Registry Management

Principles & practice, Hutchison, Menck, Et al.


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PRIMARY SITE: FEMALE

TOT# ANALNON ANA Wh B Oth W B Oth

Sys:H&NexclLarynxLIP 2 1 1 2 0 0 0 0 0TONGUE, BASE 10 9 1 7 0 0 0 3 0TONGUE,OTHER/NOS 5 5 0 4 0 0 0 1 0GUM 0 0 0 0 0 0 0 0 0FLOOROFMOUTH 3 3 0 2 0 0 0 1 0PALATE 1 1 0 1 0 0 0 0 0OTHER/NOSMOUTH 2 2 0 2 0 0 0 0 0PAROTIDGLAND 3 3 0 2 0 0 0 1 0MAJORSALIVARYGL 0 0 0 0 0 0 0 0 0TONSIL 8 8 0 4 0 0 0 4 0OROPHARYNX 5 5 0 4 0 0 0 1 0NASOPHARYNX 1 1 0 1 0 0 0 0 0SUBTOTAL 40 38 2 29 0 0 0 11 0Sys:Gastro-Intestinal TOT# ANAL NON Wh Bl Oth W B Oth

ESOPHAGUS 21 21 16 1 4STOMACH 17 15 2 10 4 3SMALLINTESTINE 4 3 1 3 1COLON 45 39 6 33 4 3 5RECTOSIGMOID JUNC 5 5 5RECTUM 28 28 19 2 7ANUS/ANALCANAL 3 2 1 3LIVER/INTRAHEPATICBIL 28 28 21 3 4GALLBLADDER 4 2 2 1 2 1BILARYTRACTOTHER 3 3 3PANCREAS 21 20 1 16 1 4OTHER-DIGESTIVE 1 1 1SUBTOTAL 180 166 14 130 4 14 0 31 1Sys:Respiratory(+Larynx) TOT# ANAL NON Wh Bl Oth W B Oth

NASALCAV,MIDDLEEAR 2 2 2ACCESS SINUSES 1 1 1LARYNX 18 16 2 15 1 2LUNG/BRONCHUS 140 131 9 125 4 11THYMUS 1 1 1SUBTOTAL 162 151 11 143 0 5 0 14 0Sys:Bones,Joints,Articul TOT# ANAL NON Wh Bl Oth W B Oth

BONES/JOINTS/ARTICULAR 3 2 1 2 1SUBTOTAL 3 2 1 2 0 0 0 1 0Sys:Hematopoetic, Reti TOT# ANAL NON Wh Bl Oth W B Oth

HEMATOPOIETIC/RETICULO 76 58 18 56 4 6 2 8SUBTOTAL 76 58 18 56 4 6 2 8 0Sys:LymphNodes TOT# ANAL NON Wh Bl Oth W B Oth

LYMPHNODES 44 27 17 34 2 3 5SUBTOTAL 44 27 17 34 2 3 0 5 0Sys:Skin(exclreproductive) TOT# ANAL NON Wh Bl Oth W B Oth

SKIN 74 66 8 50 2 22SUBTOTAL 74 66 8 50 2 0 0 22 0Sys:Retreperitoneum&Per TOT# ANAL NON Wh Bl Oth W B Oth

RETROPERITONEUM & PERI 1 1 1SUBTOTAL 1 1 0 1 0 0 0 0 0Sys:Connective/SubQ TOT# ANAL NON Wh Bl Oth W B Oth

CONNECTIVE/SUBCUTANEOU 6 5 1 3 1 2SUBTOTAL 6 5 1 3 0 1 0 2 0Sys:Breast(exclskin) TOT# ANAL NON Wh Bl Oth W B Oth

BREAST 20 16 4 16 3 1SUBTOTAL 20 16 4 0 16 0 3 0 1Sys:Female Genital TOT# ANAL NON Wh Bl Oth W B Oth

CORPUS UTERI 1 1 1OVARY 1 1 1SUBTOTAL 2 2 0 0 2 0 0 0 0Sys: Male Genital TOT# ANAL NON Wh Bl Oth W B Oth

PENIS 1 1 1PROSTATEGLAND 250 195 55 182 35 33TESTIS 6 5 1 4 1 1SUBTOTAL 257 201 56 187 0 36 0 34 0Sys:Urinary TOT# ANAL NON Wh Bl Oth W B Oth

KIDNEY 34 30 4 24 8 2RENALPELVIS 1 1 1URETER 1 1 1BLADDER 48 47 1 37 2 4 5URINARYORGANS-OTHER/N 2 2 2SUBTOTAL 86 80 6 65 2 12 0 7 0Sys:Eye&CentralNerv TOT# ANAL NON Wh Bl Oth W B Oth

EYE/ADNEXA 3 3 1 1 1MENINGES 5 4 1 4 1BRAIN 14 12 2 11 1 1 1SPCORD,CRANIALNERVES 1 1 1SUBTOTAL 23 20 3 17 2 1 0 3 0Sys: Thyroid TOT# ANAL NON Wh Bl Oth W B Oth

THYROIDGLAND 17 15 2 12 2 1 2OTHERENDOCRINEGLANDS 2 2 2SUBTOTAL 19 17 2 14 2 1 0 2 0Sys:Other i l l-defined TOT# ANAL NON Wh Bl Oth W B Oth

OTHERILL-DEFINEDSITE 2 2 1 1SUBTOTAL 2 0 2 1 0 0 0 1 0Sys: Unknown TOT# ANAL NON Wh Bl Oth W B Oth

UNKNOWNPRIMARYSITE 11 10 1 10 1SUBTOTAL 11 10 1 10 0 1 0 0 0

TOTAL 1006 860 146 742 36 80 5 141 2

CASELOAD MALERACE RACE


Cancer CommitteePeterWu,MD(Chair)

TheCancerCareCommittee is com-prised of representatives from eachofthemedicalcenterspecialtiesthatparticipate in thecareof cancerpa-tients includingthealliedhealthde-partmentsinvolvedincancer-relatedsupportive care. The Committee ischarged with the establishment and maintenance of an accredited can-cerprogramthatassistspatientsandtheirfamiliesthroughthecontinuumof care.

The Cancer Care Committee is in-volved with the entire spectrum ofcancer patient care and is respon-sible and accountable for all Cancer Care Program activities. Two majorresponsibilitiesofthecommitteeareto oversee the Cancer Registry andthe multidisciplinary Cancer Confer-ence(TumorBoard).TheCommitteeisalsoresponsibleforadvisingtheEx-ecutiveCommittee andCancer CareProgram of any issues related to on-cology practice standards aswell assponsoringinvestigationalapproach-estopatientcare.

TheCommitteeleadstheCancerCareProgram through goal-setting andimplementation,evaluation,and im-provement of cancer-related activi-tiesthroughoutthefacility.TheCom-mittee establishes annual goals andmonitors progress in the following categories:programmatic,qualityim-provement,andclinical care.Duringthepastyear, theCommitteeestab-lished and completed goals related totheareasofqualityimprovement,community outreach, and clinical im-provement.

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TumorBoardActivities for 2014 VictoriaCampa(CompileddataisfromJan.2014throughNov.2014)

The VA Puget Sound Health CareSystem Tumor Board is held everyWednesday from 1:00 p.m. to 2:00 p.m. in Building 100, RoomBD-152.Tumor Boards provide clinical in-formation, pathologic staging, andtreatment recommendations for thepatient’sdisease.

The Tumor Board is composed of a multidisciplinary group of attendingphysicians, fellows, residents, physi-cian assistants, nurses, medical stu-dents, and other health care profes-sionals. Staff representatives fromMedical,Surgical,andRadiationOn-cology act as discussants. All surgical subspecialtiesarerepresented.Imag-es and micrographs are presented by staffphysiciansfromDiagnosticRadi-ology and Pathology. The conference providesaforumtodisseminatethemost current information on cancermanagement.Thediscussantsreviewdata from current publications anddetermine eligibility of patients forcooperative group trials sponsoredby the Southwest Oncology Group (SWOG) as well as in-house clini-cal trials. The conferences providecontinuing medical education andprovide a convenient forum for ex-peditious management decisions ofcomplexpatients.

In 2014, therewere 45 conferencesfor the year. All the major cancer sites were represented in the cases discussed.Theaverageattendanceateach conference was 21. Attendeescanreceiveonecredithourcontinu-ingmedicaleducationcategory1per

session, which can be applied toward re-licensure requirements in Wash-ington State.

AllrequestsforTumorBoardsubmis-sion shall be ordered online in CPRS ontheordertab.Therequestingser-vicemustcompletetheconsulttem-plate and include a reason for the request. All consult requestswill becoordinatedthroughVictoriaCampa,Tumor Board Coordinator, Oncology Section(6-4757).

Tumor Board 2014 Distribution of 399 Total Cases (1/1/14 – 11/12/14)

THORAX 155 38.8%

HEAD&NECK 97 24.3%

DIGESTIVE 81 20.3%

SKIN 16 4.0%

UNKNOWN 15 3 . 8%

GENITOURINARY 10 2.5%

LYMPHOIDNEOPLASMS 10 2.5%

MUSCULOSKELETAL 9 2.3%

BREAST 2 0.5%

CENTRALNERVOUSSYSTEM 2 0.5%

OPHTHALMIC 0 0.0%

NON-CANCEROUS 0 0.0%

OTHER 0 0.0%



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Tumor Board Activities (Continued)

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Oncology Clinical Trials- 2013finaldata&JanuarythroughNovember25,2014interimdataJeannine Barton and Stephanie Magone

Clinical trials in oncology are studies that test, and often compare, treat-mentsinaspecificgroupofpatientswithagivencancer.Clinicaltrialsde-fineandadvancebesttreatmentsforpatient care. Through some clinicaltrials,patientsmayalsoaccessnoveldrugs for treatment of their diseases. Cancer clinical trials are therefore avitalpartof thecareoncologypa-tientsreceiveattheVAPugetSound.

VA Puget Sound actively partici-patesasamemberinstitutionoftheSouthwest Oncology Group (SWOG)and NCI-Clinical Trial Support Unit (CTSU)/NCI-National Clinical TrialsNetwork(NCTN).CancerpatientsarealsoofferedparticipationintheFredHutchinson Cancer Research Center (FHCRC) peripheral blood stem cell(PBSC) transplant protocols. In ad-dition, cancer patients are offeredparticipation in appropriate phar-maceuticalindustry-sponsoredstud-ieswith novel therapies, aswell asin-house protocols. Examples of VAsupportedpharmaceutical industry-sponsored studies include; chemo-therapycombinationregimenspriorto stem cell transplantation and toreduce the riskof sideeffects fromstemcell transplantation,preventa-tive medications to reduce chemo-radiotherapy sideeffects, advancedstage cancer treatment options,new chemotherapy treatment op-tions for different typesof cancers,and preventative vaccine studies inpatientsdiagnosedwithcancer.

Our commitment to clinical trials in-volves a multidisciplinary team ofphysicians including medical, radia-tionand surgical oncologists aswellas physicians of other surgical and medicalsubspecialties.Patientswithhead and neck, thoracic, gastrointes-tinal and hematologic malignanciesarediscussedatthemultidisciplinarytumorboardandareofferedclinicaltrial participation by the oncologyresearch staff. Patients are only re-ferred to VA Puget Sound approvedresearch studies. Stem-cell trans-plant patients are enrolled in spon-soredprotocolsapprovedby theVAPugetSoundasapartoftheirroutineclinical care.

All patients diagnosed with cancerthat are seen by a physician at VAPuget Sound are pre-screened by the Clinical Research Coordinators regarding eligibility for enrollment in a clinical trial. Once pre-screened, if a patient appears to be eligible fora clinical trial, the patient’s treatingPhysician, Clinical Research Coordi-nators, and/or clinical trial PrincipalInvestigator/Physicianwillpresentin-formation regarding the clinical trialtothepatientfortheirconsiderationof participating in the clinical trial.Information about actively enroll-ing clinical trials at VA Puget Soundis available in the research kiosksthroughout the facility, displayed on the reader boards throughout the facility,andavailableonhttps://Clini-calTrials.gov.

In2013 (finaldata),67cancerpa-tientsatVAPugetSoundelectedtoparticipateinclinicaltrials.Withinthese67enrolledpatients, 31pa-tientsenrolledintreatmentrelatedclinicaltrials,8patientsenrolledinpreventative treatment trials, and28patientsenrolledinothertypesof cancer related trials.

Todate, in2014(interimdata),52cancerpatientsatVAPugetSoundelectedtoparticipateinclinicaltri-als. This percentage for clinical tri-als enrollment was compiled from enrollment data gathered January 1, 2014 through November 25,2014,butmaynotreflectthefinalclinical trial enrollment data for 2014. Within these 52 enrolledpatients, 23 patients enrolled intreatment related clinical trials, 11 patients enrolled in preventativetreatmenttrials,7patientsenrolledinqualityof life relatedtrials,and29patientsenrolledinothertypesof cancer related trials.


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

The VA Puget Sound Oncology Divi-sionprovides initialmedical diagno-sis, medical treatment, and follow-up careforVeteransdiagnosedwithcan-cer. The division works closely withsurgicalsubspecialtiesandRadiationOncology to offer multidisciplinarycare; and with social work, nursing, dietary, chaplaincy, and other allied healthcare services toprovideholis-ticcare.Careandtreatmentforcan-cerpatientsisfrequentlycoordinatedthrough a multidisciplinary TumorBoard.Inthisforum,individualcasesandtherapeuticoptionsarereviewedby representatives from all servicesand a consensus recommendationis rendered. Oncology nurse coordi-nators from the Oncology Divisionensure follow-up, coordinates diag-nosticandtherapeuticrecommenda-tions,andmaintainscontactwiththepatient. In addition, a well-staffedCancer Care Clinic provides ongoingchemotherapeutic, transfusion, andsupportive services for patients un-dergoing treatment.

TheOncologyDivisionprovidescareinbothinpatientandoutpatientset-tings.Patientsareevaluatedandfol-lowed at four weekly subspecialty outpatient clinics staffed by attend-ing physicians who are also facul-tiesof theUniversityofWashingtonand fellow physicians from the Fred Hutchinson Cancer Center. Chemo-therapy and treatment related care is provided in the newly remodeledCancerCareClinicthatoperatesfivedays per week and staffed by twophysician assistants, two nurse prac-

titioners, three RNs, and one clerk.This unit provides all of the outpa-tient chemotherapy for VA PugetSound Health Care System patientsandalsoprovidesaconvenientloca-tionforoutpatientprocedures,suchas bone marrow aspirates and physi-calexaminations,outsideofthereg-ularoutpatient clinic hours. A full-time clinical pharmacist manageschemotherapy for both inpatientsandoutpatients,andensuressafetyofdrugadministration.

Newin2014,theDivisionhasaddeda four member cancer navigationteamto supportpatientswhomusttravel great distances or are chal-lengedwithdifficultpersonalissues.This navigation team, consists of anursepractitioner,anursecoordina-tor, a social worker and a clerk, main-tains contact with the patient andprovides throughout his/her cancercare journey. The navigation teamalso ensures seamless transition ofthepatientbacktothereferralfacil-ity and provider. Additionally, theteamwillprovidesurvivorshipcoun-seling to patients, who have com-pleted treatment.

The Marrow Transplant Service re-mainsamarqueeprogramoftheVAPuget SoundOncologyDivision. TheMarrowTransplantUnit(MTU)isoneof only three such units nationwideunder thenationalVAprogram.TheMTU performs approximately 50-60 transplants per year on patientsreferred from both remote and re-gional sites. The MTU works in close

collaborationwiththeFredHutchin-son Cancer Research Center, and the treatment and experimental proto-cols for transplantation are sharedbetween the two institutions. Afterthe acute transplant phase, the MTU performs outpatient follow-up ontransplanted patients aswell as an-nual long-term follow-up. The MTU isadiscretephysicalpatientcareunitwithintegratedoutpatientandinpa-tient care, and a dedicated nursingandclericalsupportstaff.

As always, the Oncology DivisionsupportstheoveralldirectionoftheVA Puget Sound Cancer Committee,a multidisciplinary committee thatmaintains accreditations and pro-motes cancer care activities of theinstitution. AsapartofthemissiontoprovideVeteranswithcuttingedgecancer 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 andadvancedoncologi-cal concepts. Our clinical research programparticipatesinanumberofstudiesthroughnationalcooperativeprograms and pharmaceutical spon-sors;andisstaffedwiththreeclinicalresearch coordinators. The Oncology DivisionadditionallymaintainsalocalcancerregistryunderacertifiedCan-cer Registrar; and undergoes regu-lar clinical and system improvementevaluationsundera full-timequalityimprovementcoordinator.

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

TheMarrowTransplantUnitattheVAPuget Sound Health Care System was foundedin1982.Itoperatesincon-junctionwiththeSeattleCancerCareAlliance, Fred Hutchinson Cancer Re-search Center and the University ofWashington School of Medicine. The San Antonio VA began performingmarrow transplants in 1986, joinedbytheNashvilleprogramin1995.To-gether, the threeVA transplant cen-tersprovidecomprehensivemarrowandstemcell transplantationservic-esforadultswithavarietyofmalig-nant and nonmalignant hematologic disorders.

Since 1982, close to 1,400 patientshave been transplanted in Seattle,including over 200 from unrelateddonors. Utilizing 8 inpatient bedsand 1 outpatient suite, 60-70 trans-plantsareperformedyearly.Seattlepatients receive infusion ofmarrowor peripheral blood stem cells from themselves (autologous transplanta-tion) or from amatched or closely-matchedrelativeorunrelateddonor(allogeneic transplantation). Alloge-neic transplant recipients, especially those receivingstemcells frommis-matched and unrelated donor sourc-es, require prolonged immunosup-pressionandareatriskforavarietyof complications. Immunologic tol-erance ultimately occurs with time,although close medical surveillancecanberequiredformonthstoyears.The longitudinal follow-up care and clinicaladviceprovidedbytheSeattle

program is a key element to the suc-cessful transplantation for patientsthroughout the country.

The largest proportion of patientstreated in Seattle have receivedtransplantsformultiplemyeloma,fol-lowed by non-Hodgkin’s lymphoma, acutemyelogenous leukemia (AML),Hodgkin’s disease, chronic myelog-enous leukemia (CML), and chroniclymphocyticleukemia(CLL).Multiplemyeloma, non-Hodgkin’s lymphoma and CLL are service-connected con-ditionsforveteranswithpriorAgentOrange exposure. Other malignan-cies and nonmalignant hematologic disorders are considered for trans-plantationonacase-by-casebasis.

Clinical research projects performed at the Marrow Transplant Unit in con-junction with the Fred HutchinsonCancer Research Center have led toimprovedsafetyandefficacyofmar-rowtransplantation,makingcurativetreatments available to a broadernumber of patients. Outcome datafrom patients transplanted at theMarrow Transplant Unit at the VAPuget Sound Health Care System comparesfavorablytopublisheddatain the medical literature.


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Head&NeckCancerServiceMarcDColtrera,MD,IsaacBohannon,MDandJeffreyHoulton,MD

More than 40,000 Americans (andmore than 750,000 people world-wide) are diagnosed with headand neck (H&N) cancer every year.Because veterans have dispropor-tionately high rates of smoking andalcohol use (which are two of thegreatestriskfactorsforthedevelop-mentofH&Ncancers),manyoftheseAmericansareveteransofourcoun-try’smilitaryservices.

At the VA Puget Sound Health CareSystem (VAPSHCS), cancers of thehead and neck are the third most common solid tissue cancer. OurHeadandNeckCancerServicetreatsover50newcancerpatientsand40recurrent cancerpatients each year,makingitoneofthebusiestVAH&Ncentersnationally.

Unfortunately, H&N cancers have adevastating impact on our patients’lives.Thesecancers impairthemostbasic functions responsible for ourdaily quality of life, including: eat-ing, speaking, and breathing. These cancersalsoimpactourvitalsenses,such as taste, smell, hearing, voice,andsight.Inaddition,thesetumorsmay distort our patients’ outwardphysical appearance leading to social isolation. Fortunately, we have made signifi-cant progress in treating H&N can-cers.Thanksinlargeparttoadvance-ments in technology, novel surgicaltechniques,andorgan-sparingtreat-ments (which takeadvantageof thenewest equipment and protocols),wehavemade remarkable improve-

mentsinthequalityofourpatients’livesduringandaftertreatment.

WeareoneofafewselectVAcentersthatoffermicrovascularfreetissuere-construction fordefects followheadand neck cancer resection. Thesemicrovascular techniques provideour patients with the highest formand function achievable followingtumorremoval.Inaddition,weofferourlaryngealcancerpatientslarynx-sparing trans-oral laser surgery, an al-ternativetototallaryngectomy.Thisadvanced surgical technique allowsourpatientstopreservetheirlarynx,maintainingboththeirvoiceandtheability to breath without a stoma. Our newest surgical advancementinvolvesminimally-invasive transoralrobotic surgery. Robotic surgery isan exciting new technology that al-lows tumors of the tonsils and base oftonguetoberemovedthroughthemouth rather than through a more extensive open operation. Whenused appropriately, this techniqueseems to spare patients intensivechemotherapy and radiation whichwas previously the standard of carefortreatmentofthesetumors(giventhe morbidity of open operations).Reductioninchemotherapyandradi-ationmayhaveimportantimportantimpact on our patients swallowingfunction and overall quality of life.The role of robotic surgery is cur-rently being researched both at our centerandnationally.

Weareproudtoofferthesecutting-edgetechnologiestoourpatients.Indoing so, out H&N program distin-

guishesitselfasoneoftheveryselectcenters in the country with the ability to offer patients all state-of-the-arttreatmentmodalities. Yet, themostimportant aspect of our cancer care continues to be our ability to workas a multidisciplinary team. Ourteam consists of surgical, medical andradiationoncologists,neuroradi-ologists, nurse practitioners, nurses,social workers, speech pathologists, and psychologists. Our team meets each week to discuss all new head and neck cancer patients presentedatourmulti-disciplinarycareconfer-ence(TumorBoard). Thiscollabora-tiveapproachensuresthatourtreat-mentplan isbeinguniquely tailoredtoeachindividualpatient.

Wealsocontinuetohavecross-institu-tionalcollaborationsamongstcentersin the region. We are partnered with physiciansattheUniversityofWash-ington Medical Center, where our sur-gical oncologists, medical oncologists, andradiationoncologistsallholdap-pointments on the faculty. We havesubstantial research collaborationswith faculty from the University ofWashington, the Seattle Cancer CareAlliance, and the Fred Hutchinson Can-cer Research Center. These research programs offer exciting progress to-wards treating patientswithHead&Neckcancer.Itisthroughthesemulti-disciplinary, cross-intuitional collabo-rationsthatwewillbeabletoobtainourultimategoal:toachievethehigh-estpossiblecurerates,whileofferingthehighestpossiblequalityoflifeforpatientswitheventhemostdevastat-ing Head & Neck cancers.

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RadiationOncology-ContinuousQualityImprovementasaPillarforQuality, Safety,andPatientCenteredCareTony S. Quang, MD, JD and Kent E. Wallner, MD

TheVAPugetSoundHealthCareSys-tem is a radiation oncology referralcenter in the Veterans Affairs (VA)system.ItdrawspatientsfromtheVANorthwestHealthNetwork(VISN20)which serves Alaska, Idaho, Oregonand Washington.

We deliver state-of-the art care topatientsdiagnosedwithvariousma-lignancies including head and neck cancers, lung cancer, breast cancer, gastrointestinal and genitourinarymalignancies, sarcomas, and intra-cranial neoplasms.

Our bone marrow stem cell transplant program using total body irradiationasaconditioningregimenformultiplemyeloma, leukemias and lymphomas isunrivaledwiththe implementationof safer and less toxicmyeloablativeandnon-myeloblative regimens bothinclinicalandresearchsettings.

Continuous quality improvement(CQI)isactivelyimplementedandev-ery opportunity is seized to stream-line the program. This effort isspear-headed by the radiation on-cologists—Tony S. Quang, MD, JD and Kent E.Wallner,MD. These qualityimprovementsarenotonly foundedin best clinical practice guidelines,butfortifiedwithinterdisciplinaryef-forts to ensure its robustness. Our department continues tobeaccred-ited by the American College of Radi-ology. Therecentsitevisit revealedminimal findings, and our depart-ment is poised to be re-accredited for another 3 years.

We continue to conveneweekly forinterdisciplinary chart rounds. Ra-diation oncologists, physician assis-tant, nurse, and dosimetrists attendthemeetings.Otherregularattend-ees include our social worker, Ana Fisher, MSW who has been pivotalin implementing added supportivemeasuresforpatientswhoneedan-cillary services. Our dietitian, VenusNg, RD carefully monitors weights on patientsundertreatmentandmakesrecommendations for their nutri-tionalintake.LynsiSlind,cancercarenavigator,alongwithAnaBoekenoo-gen, RN, OCN plays an important role in coordinating patient care. JasonTrumbull, PSA, has recently joined our department. He along with Corey Check, PSA and James Rapp, ASM, ensure that new consults are sched-uledexpeditiously.

Furthermore, M&M conferences are held quarterly. Physician retrospec-tive peer review is done quarterly.Physics peer review is donebiannu-ally. Focus studies are done regularly. Infact,JeanHargrett,PA-CledtheQIproject, “Reducing Inpatient Admis-sionsofCancerPatientswithMuco-sitis and Aspiration Pneumonia byImplementingStandardizedOralCareProcedure,”whichwon3rdplace atourlocalVAcompetition.

Drs. Quang and Wallner are activeparticipants at weekly Tumor Boardmeetingswherepatientsareofferedthe optimal management recom-mendations through an interdisci-plinaryeffort.Dr.Quangrunsmonth- (Continued on next page)


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ly clinical case conferences while Dr. Wallner runs monthly journal clubs teaching residents at University ofWashington Medical Center. They are Visiting Oncology Lecturers atBellevueCollegeteachingclinicalon-cologytoradiationtherapystudents.Students from this training program have consistently over the yearsscoredinthe90thto95th-percentile.

On the physics and technical side, AdamTazi,PhD,ournewChiefPhysi-cist, and Carl Bergsagel, MS are up-grading thePinnacle radiation treat-mentplanningsystemtoversion9.8,whichfixessomebugsandallowsforfurther integration of electronic re-cordanddocumentation.Wearealsoplanning to upgrade our electronic medical record— MOSAIQ Manage-mentSystemtoversion2.6,whichisthemostup-to-dateversioninthein-dustry.Implementationofthislatestversion would allow for automatedscripting and an additional layer oftreatmentverificationandqualityas-surance which meets national stan-dards. Implementation of additionalquality assuranceandpatient safetymeasures include involving JaniceShort,ARRT(T),whohasassumedtheroleofHealthInformationOfficertotroubleshoot linear accelerator soft-ware issues. Lastmonth, 4D-CT re-spiratorymanagementtechniquehasbeen commissioned to allow radia-tiononcologists totreat lungcancerpatientswithperipherallesionswithtightertreatmentmarginstoincreasetumor control and decrease treat-menttoxicities.

Intensitymodulated radiation thera-py(IMRT)continuestobeusedtreathead and neck, prostate, and lung, andrectalcancers.Volumetricmodu-

latedarttherapy(VMAT),afasterandbettertechniqueofradiationtherapydelivery, is being commissionedandwill soon be in clinical use.

Dr.Quang,Dr.Tazi,Mr.Bergsagel,Sha-ronHummel-Kramer, CMD,ARRT(T),DavidCain,ARRT(T),CMD,andDon-aldPutman,ARRT(T)continuetoim-proveclinicalandtechnicaltreatmentprecisionbyoptimizingprotocolsfordose-volume constraints and conebeamCT imaging to include specifictreatment sites. Ms. Hummel-Kram-er and Dr. Quang worked with resi-dent physician, Michael Gensheimer, MDtodevelopamathematicalmod-elpredictingsuccessinparotidglandsparing for head and neck IMRT treatment planning. This algorithm addsefficiencyas itpredictssuccessin planning allowing both the do-simetrist and the radiation oncolo-gisttohavereasonableexpectationsofparotidsparing.Thefindingswerepresentedatthe55thASTROAnnualMeetinginAtlanta,Georgia,andthemanuscript is in press.

Asanational authorityon thequal-ity assurance effort of other VAbrachytherapy programs, Dr. Wallner has pioneered a specialty clinic in the administration of seed brachy-therapyforprostatecancerpatients.Our clinic continues toofferbrachy-therapy to prostate cancer patientswho come fromevery regionof theUnited States. We have integratedbrachytherapy with a prostate can-cer program that includes IMRT with placementofgoldseedfiducials.Us-inga shortercourse—hypofraction-atedradiationtherapytreatmenthasallowed patients to complete theirtreatment quicker so they can goback home.

RadiationOncologycontinuestoplayastrongleadershiproleintheVAsys-tem.Dr.QuangprovidesourVAwithup-to-datescientificandbestclinicalpractice expertise in his respectiveroles as Co-Chair on the VA Institu-tionalReviewBoardandSurveyorforthe American College of Radiology. Dr.Quangcontinues tobeanactivemember of the Integrating Health-care Enterprise in Radiation Oncol-ogy (IHE-RO) planning and clinicaladvisory committees. IHE-RO worksin collaboration with the AmericanSociety for Radiation Oncology (AS-TRO), which addresses ways to im-prove the use of computer systemsfor information sharing, work flow,and patient care. He also serves ontheASTROBylawsCommitteeandisViceChairoftheYoungPhysicianSec-tionoftheWashingtonStateMedicalAssociation.

TheVAPugetSoundRadiationTher-apy Department has maintained its positionasanationallyvisiblecenterdrawing referrals from other VA fa-cilitiesthroughouttheUnitedStates.Our patient census remains stableand our department continues tosuccessfully implement new tech-nologyandoffersophisticatedtreat-mentplans.Ourexpansionofcuttingedge technology, continued innova-tionefforts,andourcommitmenttoqualityassurancethroughtheimple-mentation of a robust continuousquality improvement has positionedourdepartmenttoofferourpatientsthe best of care for now and well into the future.

Radiation Oncology (Continued)

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Neoadjuvantchemotherapyformuscleinvasivebladdercancer AguidelinebasedmultidisciplinaryapproachtotreatingbladdercancerMichael P. Porter, MD, R. Bruce Montgomery, MD

Bladder cancer is the 4th most com-mon non-skin malignancy in Vet-erans. At the VA Puget Sound ap-proximately 40 new cases of bladder cancer are diagnosed each year, and patientswithadvancedbladdercan-cerarereferredfromalloverVISN20(Alaska, Washington, Idaho, Oregonand Montana). Patients with tu-mors confined to the inner liningofthe bladder (clinical stage CIS, Ta,and T1) are managed initially withendoscopic resection, sometimes inconjunction with chemotherapy orimmunotherapy placed directly into thebladder.However,approximately25%ofnewlydiagnosedbladdercan-cercasesareinvasiveintothedeepermusclelayersofthebladderorhavespread to lymph nodes or other or-gansattimeofdiagnosis.Thesepa-tients with more advanced tumors(clinicalstageT2-T4,N0-3,M0-1)aremanaged with multimodal therapythat can include chemotherapy, radi-cal cystoprostatectomy (surgical re-movaloftheentirebladderandpros-tate),andradiationtherapy.

Over the past decade the standardof care for treatment with curativeintent in patients with bladder can-certhathas invadedthemuscle lay-ers of the bladder (clinical stagesT2-T4,N0,M0) in theUnited Stateshas been chemotherapy followed by cystoprostatectomy. This strategy of administering chemotherapy prior tosurgicalremovalofanorganwithcancer is termed “neoadjuvant che-

motherapy”.Eligiblepatientsreceive3-4 cycles of a specific regimen ofchemotherapy containing the agent cisplatin, followed by cystoprosta-tectomyaftercompletionofchemo-therapy. Despite level 1 evidenceand major guideline panels such as theNCCN supporting this approach,adoptionhasbeenslowintheUnitedStates.Somestudieshavesuggestedthatlessthan10%ofpatientsreceiveneoadjuvant chemotherapy, andan-other study suggested that less than 20% of patients being treated atcenters accredited by the American College of Surgeons’ Commission on Cancer receive this recommendedapproach(Figure1).

In 2010 the VA Puget Sound em-barked on a multidisciplinary effortto improve compliance with guide-lineconcordantcareforpatientswithbladder cancer, with the ultimategoaltoimprovepatientoutcomes.Akeypart of this initiativewasdevel-oping processes that improved op-portunities for patientswithmuscleinvasive bladder cancer electing forradical cystoprostatectomy to be considered for receipt of neoadju-vant chemotherapy. All potentiallyeligiblepatientswithbladdercancerhave been subsequently discussedatamultidisciplinaryconference, in-cluding medical oncology and urol-ogy surgical specialists, which meets weekly. This report describes our experiencewithneoadjuvantchemo-therapy from 2011-2013. (Continued on next page)


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MethodsWe retrospectively identified all pa-tients at VAPSHCS that underwentradical cystoprostatectomy for mus-cle invasive bladder cancer. Patientcharts were then reviewed and ba-

ResultsWeidentified29patientswhounder-went radical cystectomy for bladder cancer between January 2011 and February 2014. All patients weremale,andmedianpatientagewas69years. Demographic characteristicsare shown in table 1.

26patientshadmusclein-vasivebladdercancerandwere eligible for neoadju-vant chemotherapy. 19out of 26 patients (76%)received chemotherapy,and 14 patients (56%)completed all planned cycles (Table 2). Reasonsfor not receiving chemo-therapy included renal in-sufficiency (n=3), patientpreference(n=2)andpoorpatient compliance withmedical care recommen-dations(n=1).Reasonsfornot completing chemo-therapy included tumor non-response of progres-sion (n=3), renal toxicity(n=1) and poor tolerancewithpancytopenia(n=1).

ConclusionsOver 75% of patients with muscleinvasive bladder cancer at the VAPSHCS receive neoadjuvant chemo-therapy prior to planned cystopros-tatectomy.Thisissignificantlyhigherthan published national averages atother COC accredited hospitals, and is concordant with evidence-basedguidelines. This provides objectiveevidence that patients with muscleinvasivebladdercancerseekingcareat theVAPugetSoundarereceivingstateoftheartmultidisciplinarycan-cer care.

sic demographic information, tumorstage, comorbidities, and outcomeswere abstracted. The receipt of neo-adjuvant chemotherapy was noted,aswerethereasonsfornotreceivingneoadjuvantchemotherapy.

Neoadjuvant chemotherapy for muscle invasive bladder cancer (Continued)

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DiagnosticImagingService(DIS)Julie Takasugi MD and Joseph G Rajendran, MD,

Diagnostic radiology and nuclearmedicineareimportantfieldsinde-tection, diagnosis, treatment andfollow up of a variety of diseases,including malignancies. DiagnosticImagingServices(DIS)isresponsiblefor the performance of quality ex-aminations, interpretation of thoseexaminationsandforthecommuni-cationof study results to the refer-ringclinician inatimely fashion.AttheVAPugetSoundHealthCareSys-tem (VAPSHCS), Seattle and Ameri-can Lake Divisions, there are 8 re-ceptionists/schedulers, 2 programsupport persons, 1 administrativeofficer,2PACSadministrators,3fileclerks, 2 health technician/escort,34radiologic/nuclearmedicinetech-nologists,5technologystudents,1.4FTE Nurse Practitioners, 1 nurse, 8residents,2 fellows,9 full-timeand2part-timeattendingphysicians.At-tendingradiologistssubspecializeinabdominal imaging, cardiothoracic radiology,gastrointestinalradiology,neuroradiology, musculoskeletal ra-diology,nuclearmedicine(diagnosisand therapy) or vascular and inter-ventionalprocedures.

Services provided by DIS includeconventional radiographic exams,fluoroscopic studies of the gastro-intestinal and genitourinary tractsandnervoussystem,computedaxialtomographic (CT) scans, ultrasoundexams,magnetic resonance imaging(MRI),angiographyandradionuclidestudies. Modern CT, SPECT/CT andPET/CTscannershavebeeninstalled.ThePET/CTacollaborativeeffortwith

R&D in providing clinical PET scancapability at VAPSHCS and we havestarted of with 18F-fluorodeoxyglu-cose imaging. Mammography is per-formed at VirginiaMason, UW, andother local imaging centers that are accessible topatients.Percutaneousbiopsies, aspiration and drainage offluid collections, biliary and genito-urinary drainage, long-term intrave-nous catheter placement, percutane-ous feeding tube placement, tumor embolization and ablation proce-dures, intra-arterial chemotherapy accessandintravascularstentplace-mentaresomeofthediagnosticandtherapeutic procedures offered bythis department. In nuclear medi-cine, all general nuclear imaging studies including myocardial perfu-sionstudies,brainSPECTimaging(in-cluding DAT scan), In-111Octreotideand I-123MIBG scans and lymphos-cintigraphyareperformed.AmodernSPECT/CT (16 slice) was installed atSEA. Therapy with radiopharmaceu-ticals is routinely performed for hy-perthyroidism, thyroid cancer (usingIodine131)andbonepainpalliation(using Strontium 89 and Samarium153). Radioimmunotherapy (withYttrium 90 Ibritumomab tiuxetan)for treating non-Hodgkins lympho-ma and Ra-223 chloride therapy for metastatic prostate cancer are nowavailable for our patients. VAPSHCSprovidesteleradiologyservicefortheinterpretation of nuclear medicinestudies performed at Spokane VAHospital. Inaddition,DIS supportsanumber of committees and confer-ences dealing with cancer patients

at its Seattle Division, includingTumor Board, Cancer Committee,Tumor Registry, Gastroenterology-Surgery Conference, Neurology/Neuro-Surgery Conference, Livertumor conference and Genitouri-nary Conference. In 2014, a total of98,000 radiologicexaminationswere performed at the VAPSHCS.Diagnostic Imaging also providesconsultationonstudiesperformedat outside hospitals and teleradiol-ogyservicesforotherVAhospitalsinVISN20.


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Thoracic Surgery 2014LeahM.Backhus,MD,MichaelS.Mulligan,MD,ThomasMcDonough,PA-C

The Thoracic Surgery service at theVAPugetSoundHealthCareSystem(VAPSHCS)hasbeenanactivepartici-pantinthecareofVeteransinthePa-cific Northwest formany years. TheThoracicSurgerysectionisanintegralpartoftheDivisionofCardiothoracicSurgery at the University of Wash-ington, which attends to all aspectsof thoracic pathology. We are dedi-cated to the prevention, detection,treatment and research of thoracic diseases.

OurserviceconsistsofDr.LeahBack-hus, Dr. Michael Mulligan and Mr. Thomas McDonough, PA-C. Dr. Back-hus is an assistant professor of sur-geryattheUniversityofWashingtonwith clinical and research emphasis on thoracic oncology and lung trans-plantation.Dr.MichaelMulligan isaprofessorofsurgeryattheUniversityof Washington and is director of the lung transplant and minimally-inva-sive thoracic surgery programs andSection Chief for Thoracic Surgery.The team is also supported by a dedi-cated Physician Assistant, Thomas McDonough, who has been a part of the section for over ten years. Weofferawidevarietyofsurgicaltreat-mentoptions forpatientswithbothbenign and malignant diseases.

Lungcancerisoneofthemostcom-mon solid tumors encountered in our nation’s Veterans and it constitutesthe majority of the Thoracic Surgery practice at the VA. In addition tolung cancer, we provide treatmentfor mesothelioma and malignancies involvingthetrachea,chestwall,me-diastinum,esophagusandsecondarypulmonary metastases. We utilize

a multidisciplinary approach to thethoraciconcologypatientandcollab-orate with our colleagues in Pulmo-nary Medicine, Radiation Oncology,Medical Oncology, Radiology, Nucle-arMedicine and Pathology. Patientsrequireanumberofdiagnosticteststhat are coordinated by the Physician Assistant. Preoperative counselingandtestingareperformedintandemwith the Pulmonary and Oncology services within an integrated clinicstructure. Because most lung cancer patients require extended follow-upas a part of their cancer care, the Thoracic Surgery service follows allresectedlungcancerpatientsforfiveyears.Thisrequiresbiannualimaging,clinicalexaminations,andassistanceand counseling regarding smoking cessation.Alltestsandexaminationsare performed by the Thoracic Sur-gery service at a weekly outpatientclinic. Approximately fifty to sixtylungresectionsareperformedattheVAPSHCSeachyear.

Thoracic Surgery remains on the leading edge of technology and surgi-cal techniques. Weofferminimally-invasive surgery including Video As-sisted Thoracic Surgery (VATS). Thistechniqueallowsremovalofalobeofthe lung (lobectomy) through smallincisions with the assistance of a tho-racoscope. It avoids the traditionallargeincisionassociatedwithsignifi-cant morbidity and mortality in lung cancerpatients.PatientsundergoingVATS lobectomyappear tohave lesspain associated with surgery and gen-erally leave the hospital and returntonormal activity sooner.OncologicresultswithVATS lobectomy appeartobe equivalent to traditional open

thoracicprocedures.VATSisalsouti-lized in performing lung and lymphnode biopsy, as part of minimally-invasive esophageal surgery andmanagement of pleural conditions.A state-of-the art bronchoscopy suite providestheabilitytoperforminter-ventional bronchoscopy proceduresfor diagnosis, staging, and palliationof symptoms. Finally, we offer lungvolume reduction surgery to selectpatientsandweareoneofthreeVAMedicalCentersnationwideofferinglung transplantation as another op-tionforend-stagelungdisease.

Beginning in 2013, VA Puget Soundhas partnered with members of the Portland VA to create the VISN 20Specialty Care Access Networks – Ex-tension for Community Healthcare Outcomes (SCAN-ECHO) Program.The team is led by Pulmonary Medi-cine and includes Thoracic Surgery, Radiology, Medical Oncology and Palliative Medicine. SCAN-ECHO isa form of tele-health promoted by theVAOfficeofSpecialtyCareTrans-formation. Duringweeklyhour-longSCAN clinics, clinical case presenta-tionsarecombinedwitheducationalsessions for the target audience of primary care providers from ruralandunderservedareas. Dr.Backhusisaclinicalspecialistfacultyprovidingeducationandconsultationontopicsrelevant to Thoracic Surgery whichinclude:

• Pre-Operative Evaluation of thePatientUndergoingLungSurgery

• TransitioninCareFollowingLungCancer Treatment

• Surgical Management of COPD: LungVolumeReductionSurgery

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Surgical OncologyPeter C. Wu, MD

The surgical oncology program provides comprehensive evalua-tionand treatment for tumorsofthe upper and lower gastrointes-tinal tract, hepatobiliary system,pancreas, breast,melanoma, softtissue sarcoma, and endocrinesystem. Together with Drs. Lor-rie Langdale, Roger Tatum, DanaLynge,EdgarFigueredo,andDeb-orahMarquardt;our sectionpro-videssurgicalexpertisecoveringabroad range of procedures, includ-ingsentinellymphnodemapping,minimallyinvasiveandroboticsur-gery, and complex oncologic resec-tions including esophagectomy,hepatic resection, pancreaticodo-duodenectomy and total meso-rectal excision with anal sphincter preservation.Weworkintandemwith colleagues in Medical and Ra-diationOncologytoofferpersonal-izedcombinedmodalityprotocols.Ourgoalsaretoprovidestate-of-the-art solid tumor treatment in a multidisciplinary environment,enroll patients in cancer clinicaltrials, conduct innovative cancerresearch, and provide educationand mentorship to our students, residents, and fellows affiliatedwiththeUniversityofWashingtonand Fred Hutchinson Cancer Re-search Center.

Urologic Oncology ProgramBruce Montgomery, MD, Michael Porter, MD

The multidisciplinary Urologic On-cology program is designed to help patients with genitourinary cancersof all types and give them the op-portunitytodiscusstheirtherapeuticoptions with a broad range of careproviderswhotreatpatientswiththisdisease, including urologists, radia-tiononcologists,medicaloncologistsand endocrinologists. By providingthis type of integrated patient care,doctors hope to help patientsmakeinformed decisions and receive thebest possible treatment. The multi-disciplinary teamofferssomeof themost advanced treatment optionsavailable forprostatecancer, includ-ing nerve sparing prostate surgery,brachytherapy (radiation implants),adjuvant chemotherapy and ad-vanced disease chemotherapy stud-ies. The center is one of a select few VA centers in the country utilizingthe DaVinci robotic system to per-formprostatectomies.Wealsooffer

cutting edge treatment options forkidney and bladder cancer, including robotic partial nephrectomy, laparo-scopic nephrectomy, energy based ablative techniques for small renaltumors, radical cystectomy with uri-nary diversion for muscle invasivebladder cancer, and adjuvant thera-pies for non-muscle invasive blad-der cancer including chemotherapy placed into the bladder. We are a cancerreferralcenterforallofVISN20 and also provide comprehensivecare for cancers that are more un-common in the Veteran population,includingtestisandpeniscancer.TheProgram is the national coordinat-ingcenterforarandomizedstudyofhow to prevent relapse of prostatecancer after prostatectomy and hasother prostate cancer study proto-cols open. For information, contactthe Oncology Department at (206)764-2709ortheUrologyDepartmentat(206)764-2265


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Whole Health Healing and OncologyDawn Irene Aragón, PhD

As the VA Puget SoundHealth CareSystem (VAPSHCS) Oncology pro-gramshaveexpandedtoprovidecareformorehematologic/oncologicdis-orders,sohavetherolesofallhealthcareproviders.Aplethoraofresearchshows a clear relationship betweenstress and illness.

Inordertoprovideourveteranswith21st Century Health Care The VAWay, TheOfficeof Patient CenteredCare and Cultural Transformation(OPCC&CT)wasestablished in2010.The OPCC&CT is working with VHAleadershipandotherprogramofficesto transform the system of health care from the traditional medicalmodel to a personalized, proactive,patient-drivenmodel.OPCC&CThascontractedoutanddevelopedusefulmaterialsontheHealthForLifeweb-site. This approach is aligned with the VHAStrategicPlanFY2013-2018andtheNational LeadershipCommittee-VeteransExperienceCommittee. The OPCC&CT is dedicated to sup-portingthefieldintheculturaltrans-formation toHealth forLife.Theof-ficeexists toprovide resourceshelpexpand evidence-based strategiesthat enhance the health and well-beingoftheVeteransweserve.

Everything is connected to every-thing.TheComponentsofProactiveHealth and Well-Being can be fully explained here: http://healthforlife.vacloud.us/index.php/components-of-proactive-health-and-well-being

Personalized Health Plan (PHP)

The Personal Health Inventory (PHI)is a customized plan that is over-arching in scope and is designed to optimize the health and well-beingof each patient according to whatmatters to himor her. The PersonalHealthPlan(PHP)isacombinationofclinical information and knowledgeand the patient’s mission, healthgoals, and priorities. It is created ina partnershipbetween thepatient’shealthcareteamandthepatientandisdevelopedataface-to-faceortele-phonevisitwiththepatient.Thepa-tient-drivenPHPisatoolthatcanbeutilizedtodevelopasetofresourcesand support teams available to thepatient as well as the next steps inprofessional care. Both the PHI and PHP are living re-cordsofthepatient’scare.Whenev-erthepatient’sconditionorcircum-stances change, and at least once a year,thecareteamshouldrevisitthehealthplanwiththepatienttomake

sure it always meets his or her goals forhealthand life.Thepersonalizedhealth approach encompasses all as-pectsoftraditionalcare,fromoutpa-tienttolong-termandrehabilitation.Buildingfromtheirvaluesandgoals,thePHIandPHPdevelopaplanthataddresses all components of a pa-tient’shealthandwell-being.

Whole Health Resources:OfficeofPatientCenteredCareweb-site:http://healthforlife.vacloud.us/

Whole Health Curriculum: http://healthforlife.vacloud.us/index.php/research-education/education

To learn more about PCC & CT, a 4-partpresentationbyTracyGaudet,MD (Director, Washington, DC) in-cludes:

1. What Matters Most: Personal-ized, Proactive, Patient-DrivenCare [16 min]

h t tp : / /www.youtube .com/watch?v=auhwb9qQ8VE

2. ChangethePractice:WhyPatientCenteredCare[7min]

http : / /www.youtube .com/watch?v=auhwb9qQ8VE

3. Experience the Change: The Ele-ments of Patient Centered Care[20 min]

h t tp : / /www.youtube .com/watch?v=Fehn04VUCWM

4. WhatVeteransValue:TheFutureofVHAHealthCare[26min]

http : / /www.youtube .com/watch?v=D0EzTU9lTb4

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Cancer Telemedicine ProgramPeter C. Wu, M.D.

NutritionandCancerMelissaPowell,RD,WingYan(Venus)Ng,RD,CNSC

Nutrition is essential in contribut-ing to optimal outcomes in patientsundergoing cancer treatment. Eat-ing well during cancer treatment can help patientsmaintain strength andenergy, decrease their risk of infec-tion,andreducethesideeffectsfromtreatment.Patientsundergoingcan-cer treatment can experience numer-ous side effects that can adverselyaffecttheirabilitytomaintainpropernutrition: nausea, vomiting, earlysatiety, diarrhea, taste and/or smellchanges, difficulty with swallowing,andlossofappetite.Weightlosscanresultfromthesesideeffectsandcanputpatientsathigherriskofhospital-ization,andpotentiallydelaysurgery.Nutrition and Food Services at VAPuget Sound Health Care System pro-vides nutrition education and coun-selingbyRegisteredDietitians toRa-diationOncology,CancerCareClinics,MarrowTransplantUnitpatientsandtheir caregivers on an individual andgroupbasis.Topicsofevidence-basededucation and counseling includeweight management, food safety, can-cer reoccurrence prevention, basichealthy eating, Diabetes education,and symptom management. Many patientswillrequireafeedingtubetomaintainnutritionandhydrationdur-ing andafter cancer treatment. Thedietitian provides tube feeding for-mula recommendations to patientsandproviders,providesinstructiononfeeding andhydration, utilizing feed-ing pumps, and monitors tube feeding tolerance and progression.

Many patients undergoing BoneMarrow Transplants may requiretotalparenteralnutrition(TPN)dur-ing their treatment. In this case, the dietitian provides TPN recom-mendations and monitors patients’

nutritional status throughout thetransplantprocess. Inaddition,thedietitianprovidesguidanceandpol-icyoversighttotheprovisionofhighqualitypatientfoodservice.

Our Nutrition Support Team, (NST)continuestomeetweeklytodiscusshigh risk patients, current articles,andtomakesurethatwearealluti-lizing the most current evidencedbasednutritionpractices. Ourteamincludes several Clinical Dietitians,Doctors from GI and Surgery, and a Pharmacistasavailable.Wealsocon-tinuetoworkcloselywithPharmacyas we are enjoying the ability to cus-tomizeourTPN.

This Spring, we established two out-patientnutritionclinicsforRadiationOncology and Cancer Care to meet thegrowingneedsofnutritionedu-cation, dietary counseling, weightmonitoring, and nutrition supportmanagement in this high risk popu-lation. Over the past few months,theutilizationofthesenutritionclin-icshasbeenincreasing.Onaverage,60%ofthepatientsweseearehead& neck cancer patients whomostlyrequire supplemental or total en-teral nutrition support. About 30%areesophageal cancerpatientswhoareundergoingdefinitiveorpalliativetreatments. The rest is mostly other gastrointestinal cancers, e.g. gastricandpancreaticcancers,andlungcan-cer. Our department has been work-ingonVISN20OutpatientEnteralandOral Nutrition Supplement ProductsPolicy, which will soon allow Clinical Dietitians to prescribe oral supple-ments for outpatients who meetspecificmalnutrition criteria orwhoare undergoing certain pre-surgical evaluationandpreparation.

The Cancer Telemedicine Pro-grambasedattheVAPugetSoundis broadcast twice monthly and serves to advise and coordinatemultidisciplinary oncology carethroughout theVeterans Integrat-edServiceNetwork(VISN)20.Orig-inally conceived as the NorthernAlliance Cancer Center and funded by the VA New Clinical InitiativesProgram and VACO Transforma-tional Initiatives Program, the VACancer Telemedicine Program has matured into a vital clinical pro-gram for the region. Providers atregional VA facilities throughouttheVISN20presentcasesinaliveinteractiveformattothemultidis-ciplinary tumor board in Seattlestaffed by surgical, medical, ra-diation, and thoracic oncologists.Participation in this program fa-cilitatespatientreferral,minimizesconsultationdelays,avoidsunnec-essary patient travel, coordinatesoutpatient studies, and providesmultidisciplinary evaluation of allcancer patients. The program’ssuccess ensures that all veteranswithintheVISN20haveaccesstostate-of-the-art multidisciplinarycancer care. Over the past year,wehaveexpandedtheprogramtoinclude sites represented by the Spokane, Boise, Anchorage, and WallaWallaVAcenters.

For further information, pleasecontact our Cancer Telehealth Coodinator,LisaMandell,R.N.,J.D.e-mail:[email protected]


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NutritionandCancerMelissaPowell,RD,WingYan(Venus)Ng,RD,CNSC

Nutrition is essential in contribut-ing to optimal outcomes in patientsundergoing cancer treatment. Eat-ing well during cancer treatment can help patientsmaintain strength andenergy, decrease their risk of infec-tion,andreducethesideeffectsfromtreatment.Patientsundergoingcan-cer treatment can experience numer-ous side effects that can adverselyaffect theirability tomaintainprop-er nutrition: nausea, vomiting, earlysatiety, diarrhea, taste and/or smellchanges, difficulty with swallowing,andlossofappetite.Weightlosscanresultfromthesesideeffectsandcanputpatientsathigherriskofhospital-ization,andpotentiallydelaysurgery.Nutrition and Food Services at VAPuget Sound Health Care System pro-vides nutrition education and coun-selingbyRegisteredDietitians toRa-diationOncology,CancerCareClinics,MarrowTransplantUnitpatientsandtheir caregivers on an individual andgroupbasis.Topicsofevidence-basededucation and counseling includeweight management, food safety, can-cer reoccurrence prevention, basichealthy eating, Diabetes education,and symptom management. Many patientswillrequireafeedingtubetomaintainnutritionandhydrationdur-ing andafter cancer treatment. Thedietitian provides tube feeding for-mula recommendations to patientsandproviders,providesinstructiononfeeding andhydration, utilizing feed-ing pumps, and monitors tube feeding tolerance and progression.

Many patients undergoing BoneMarrow Transplants may requiretotalparenteralnutrition(TPN)dur-

ing their treatment. In this case, the dietitian provides TPN recom-mendations and monitors patients’nutritional status throughout thetransplantprocess. Inaddition,thedietitianprovidesguidanceandpol-icyoversighttotheprovisionofhighqualitypatientfoodservice.

Our Nutrition Support Team, (NST)continuestomeetweeklytodiscusshigh risk patients, current articles,andtomakesurethatwearealluti-lizing the most current evidencedbasednutritionpractices. Ourteamincludes several Clinical Dietitians,Doctors from GI and Surgery, and a Pharmacistasavailable.Wealsocon-tinuetoworkcloselywithPharmacyas we are enjoying the ability to cus-tomizeourTPN.

This Spring, we established two out-patientnutritionclinicsforRadiationOncology and Cancer Care to meet

thegrowingneedsofnutritionedu-cation, dietary counseling, weightmonitoring, and nutrition supportmanagement in this high risk popu-lation. Over the past few months,theutilizationofthesenutritionclin-icshasbeenincreasing.Onaverage,60%ofthepatientsweseearehead& neck cancer patients whomostlyrequire supplemental or total en-teral nutrition support. About 30%areesophageal cancerpatientswhoareundergoingdefinitiveorpalliativetreatments. The rest is mostly other gastrointestinal cancers, e.g. gastricandpancreaticcancers,andlungcan-cer. Our department has been work-ingonVISN20OutpatientEnteralandOral Nutrition Supplement ProductsPolicy, which will soon allow Clinical Dietitians to prescribe oral supple-ments for outpatients who meetspecificmalnutrition criteria orwhoare undergoing certain pre-surgical evaluationandpreparation.

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

A new diagnosis of cancer can be overwhelming physically and emo-tionally. Diagnosis and treatmentoften require complex coordinationbetween many disciplines within our largehealthcaresystem. Inaddition,manyVeterans travel long distancestotheVAPSHCStoreceivethiscare.For our Veterans, receiving cancercare may be further complicated by limited transportation, financialstrain, lack of social support, men-tal health issues, homelessness, and otherhealthconditions.

The Cancer Care Navigation Team(CCNT) is a VISN-funded pilot pro-gramcreatedtoidentifyandaddressbarriers that prevent Veterans fromgetting timely and efficient cancercare. There were two main goals es-tablishedbytheVISNforthefirstyearof the CCNT program: staff recruit-ment and program development.Thefirstgoalwasmetbyassemblinga fourmember teamconsistingofanurse practitioner, registered nurse,social worker and a program sup-portassistant.Ournursepractitioner,Tamarind Keating, ARNP, MPH hasexperience inprogramdevelopmentandevaluationandhasworkedasaclinician in stem cell transplant for thepastsixyears.LynsiSlind,RN,MNcameinMayofthisyearfromfifteenyearsattheUniversityofWashingtonMedical Center in Oncology where sheworkedasastaffnurseandasaClinical Nurse Educator. Ana Fisher, LICSW, OSW-C has been the Oncol-ogyandPalliativeCareSocialWorkerat VA Puget Sound since 2008 and

has experience in clinical social work in hospital and skilled nursing facil-itysettingsforthepast15years.Ms.Fisher is a Clinical Instructor for the University of Washington School ofSocial Work and has provided edu-cation to colleagues at the VA andcommunity hospice agencies on how tobestcareforVeteranswithcancerand at the end of life. Jesus Rivera,PSA, came from the VA hospital inLoma Lindawith 7 years ofmilitaryexperience in administrative, cleri-calandmedicaldutiesasHealthcareSpecialist in the U.S Armed Forces.

CCNTprogramdevelopmentrequiresidentifying individual and systemicbarrierstocancercareanddevelop-ing strategies to address them to im-prove theexperienceofcancercarepatients at the VAPSHCS. Workingcloselywith theVISNprogramman-agers and champions as well as stake-holdersatVAPSHCS,wearecreatingeducationmaterial,patientservices,andresourcesforhealthcareprovid-ers to support andenhanceexistingcancercareservices.Wearealsode-velopingnewclinicstoservehighriskVeteranswithcancer.

OurclinicisaconsultserviceforVet-erans who are considered at highest risk for cancer care barriers, namely Veterans referred to the VA PugetSoundfromanotherVAfacility.Navi-gation teams have also been estab-lished in Spokane, Walla Walla, Boise, Anchorage, Portland, Roseburg and White City. With these partners, we are easing transitions between VA

facilities by assisting with com-municationbetweenVeteransandtheir PACT and Oncology teams, arranging travel and lodging, of-fering psychosocial and symptom managementsupport,andprovid-ingeducationtoVeteransandtheirfamilies.Since June of this year, our SeattleCCNThasassistedwithcareformorethan135Veterans.

A Survivorship Clinic is also beingestablished to see Veterans whohave completed cancer therapygivenwith curative intent. ThesepatientswillreceiveaSurvivorshipCarePlanwhichprovidesarecordof their cancer treatment, a plan for future cancer surveillance andother routine health care, and adescriptionoflateeffectsthatmayoccur as a result of their cancer treatment. The clinic will include a visitwith the nurse practitionerand social worker to address both physicalandpsychosocialeffectsofcancer treatment.

In year two, the CCNT program hopes to expand our services tomore Veterans receiving cancercare to make a meaningful and measurable impact in their experi-enceattheVAPHSCS.


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Oncology Social WorkCathyBlanchard,LICSW,OSW-C,AnaFisher,LICSW,OSW-C

Whenpatientsreceiveacancerdiag-nosistheyhavemanyconcernsaboutwhat the diagnosis means, what to expect, details on medical care, con-cernsfromlovedones,finances,andsurvival. Comprehending and orga-nizing the provided information canprovokeanxiety andbeoverwhelm-ing while one is making important health care decisions. The role of theOncologySocialWorker(OSW)iscentral to helping patients, caregiv-ersandcommunitieswithdetection,prevention, navigation and survivalinarapidly-changingtreatmentenvi-ronment.OSWsareuniquelytrainedin accessing resources, recognizingdisparities in care, communication,stress reduction, familysystems,ad-vocacy, and community resources,allowing the OSW to affect positivechange in the lives of Veterans andtheir families.

Specifically,OSWsstrivetoobtainac-curate and up-to-date educationalinformation andother resources forpatients.Thehopeisthatbycontact-ingpatientsearlyintheprocessandprovidingthemwithverbalandwrit-ten material, the patients will havea better understanding of what toexpect during their treatment and willalsobebetterpreparedtocope.Social workers have been active inpublic education campaigns includ-ingworkshopsforveterans,conduct-ing training forstaffandcommunitypartners, and public message boards toinformVeteransaboutcancerpre-vention, detection and care; aswellasVeterans’benefitsandVAresourc-es. The OSW also presented a com-

ponent on cultural competence and grief, loss and bereavement duringthe End-of-Life Nursing ConsortiumintheFallof2014.Additionally,OSWsprovide ongoing education to socialworkstudentsthroughtheUniversityof Washington School of Social Work (UWSSW)practicumprogram,whichprovideshands-onexperiencetostu-dents and to provide the Universitywith input regarding Social Work in health care. In April and November2014,OSWsparticipated in theUni-versity of Washington, Interprofes-sional Education Care of Veteranstraining to Dental, Medical, Nursing, Pharmacy and Social Work students. OSW provided a training presenta-tion on End of Life Care for Veter-ans to theUniversityofWashingtonSchoolofSocialWork,CarolLaMareScholarsSeminarinMayandNovem-ber 2014.

Support groups and educational of-feringscanbebeneficialatallstagesofthecancerexperience.AtVAPugetSound, Social Workers co-facilitate a supportgroup forpatientcaregiverswhoreceivestemcell transplantsaswell as a general diagnosis support group for caregivers. Social Work,with the assistance of other depart-ments, sponsors and organizes aday-long workshop developed forVeterans and their caregivers called“Heroes of the Heart,” which pro-vides information about self-care,resources available, Medicare andMedicaid planning, advance careplanning, and estate planning. This workshop is scheduled to be held in March2015.OSWsarealsoplanning

anongoingSurvivorshippsycho-edu-cationalgroupforpatientstoprovideinformation and support regardingthe effects of cancer and treatmentonemotions,workandfamily.

Cancer treatment moves patientsinto a new awareness and self-image. Patientsandtheirlovedonesmayfeelincapable of managing independent-ly at home. OSWs are highly skilled at assessing patients’ and families’resources and referring patients tothelevelofcareappropriatefortheircurrent situation and needs, includ-ingcommunityoutpatientprograms,home health care, skilled nursing or assisted living facilities, or hospice/palliative care. OSW assisted in theimplementationoftheNCCNDistressThermometerforPatientsandisad-dressing the psychosocial needs of theVeteransattheirinitialradiationoncologyandcancercareclinicvisits.

OSWsparticipateasmembersoftheinpatient consultation team in thepalliativeandhospicecareprogram.Socialworkers,alongwithotherstaffmembers,focusonthepatient’squal-ityoflifebyassistingwithend-of-lifeplanning, care resources and emo-tional support. Additionally, OSWsprovide the patient and loved oneswithgriefandbereavementsupportand referral to resources during this transition. Social workers partici-pateinend-of-lifeeducationforstaffmembersandeducationforcommu-nity partners about the VA hospiceandpalliativecareprogram,survivorbenefits,andburialbenefits.

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OSWsare essential inAdvanceCareDirective (ACD) planning, educationand completion. Socialworkers par-ticipate in a hospital-wide initiativetoimproveVeterans’andstaffmem-bers’ understanding of living wills,durable power of attorney, and therole of surrogate decision makers. Veteransareencouragedtocompletehealthcaredirectivestoensuretheirongoing participation in their ownhealth care and to relieve stress forlovedoneswhoarenamedassurro-gate decision makers.

During the next year, OSWs at VAPuget Sound will continue to advo-cateforVeteransinourcare,reducingbarriers to care and increasing access to treatment whether through locat-ing appropriate transportation re-sourcesorfindingfinancialresourcesto allow them to keep their appoint-ments. Socialworkers conductqual-

ity training for veterans, caregivers,staff, and community members andwillcontinuetotrainstudentinternsatVAPuget Sound. SocialWorkwillcontinue to hold trainings at com-munity hospitals and institutions ofhighereducation to increaseaware-nessofVeterans’benefits,programsanduniquehealth careneeds.Withrenewed emphasis on survivorship,there are plans to hold a cancer sur-vivorship clinic at VA Puget Sound.OSWs will continue to work on thecommittee to improve the cancersurvivorshipresourcesandpassthatinformation to Veterans and medi-cal professionals at the hospital. We will continue to provide caregiverand Veteran education and supportgroups. These efforts support theoverallgoaltohelppatientsmaintaintheir quality of life while they copewithvarious issues thatariseduringcancer care.


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CancerRehabilitation/RehabilitationCareServiceMegSablinsky,PT,DPT,CLT–LANA

For patients undergoing cancertreatment, quality of lifematters asmuch—ifnotmore—thanthequan-tity of life.With an increasing focusonrehabilitation,patientsareabletohave improvedquality of life duringandaftertheircancertreatment.Pa-tients undergoing cancer treatmentmay experience one or more of the followingsideeffects:decreasedmus-cle strength, decreased bone density, peripheral neuropathy related to che-motherapy,fatigue,decreasedrangeof motion, pain, lymphedema, andscar adhesion. Rehabilitation CareServicescanassistpatientswhohavebeen diagnosed with cancer with a variety of their rehab needs on aninpatient or outpatient basis. Theseneeds include pain control, weak-nessanddeconditioning,mobilityin-cludingassessmentandprovisionofequipmentformobilitysafety,activi-ties of daily living such as dressing/grooming/bathing, cognition, com-munication, swallowing, nutrition,bowel/bladder functions, skin integ-rity and wound management, lymph-edemamanagement,depression/ad-justment/anxiety,socialsupport,andvocationalguidance.Goalsforcancerrehabilitationoften includeeffectivepain control, maximal functional in-dependence, restorationofmaximalstrengthandmobility,preventionoffurther impairment,care-givertrain-ing to assist functionally-dependentpatients, home management, com-munityreintegration,andbehavioraladaptationtopainandillness.Inaddition,aspecializedservicethatRehabilitation Care Services offersis Complete Decongestive Therapy(CDT),atreatmentfor lymphedema.

Lymphedema is swelling of a bodypart, most commonly involving theextremities,faceandneckbutitmayalso occur in the trunk, abdomen or genital area. It is most commonly the result of damage to the lymphaticsystem due to surgery or radiationtreatment therapy, surgical proce-duresperformedincombinationwiththeremovalof lymphnodessuchasmastectomies, lumpectomies, pros-tatectomies, or neck dissection pro-cedures, trauma or infection of thelymphatic system, as well as severevenousinsufficiency.Thereisnocurefor lymphedema. However, CDT canhelp reduce the swelling and main-tain reduction, and significantly im-proveapatient’squalityof life.Thiscomprehensive treatment involvesthe following four steps:

• manual lymph drainage• compressiontherapy(bandaging)• decongestiveexercises• skin care

Once the treated extremity/area isbacktoclosetonormalsizeorisnolonger reducing in size, the patientis fitted with a compression gar-ment. Patients are also taught howto selfmanage their condition aftertreatment has ended. At the end of 6-8 weeks of sessions, we can ex-pecta60%decreaseintheswelling,which facilitates functional activitiesfor these patients. In addition, thelymphedema treatment program forheadandneckpatientswillhelpthemrecovertheirabilitytoswallowandproduce saliva, voice, andROMof the neck.

Duringthis2014year,ourLymphede-maClinichasatotaloffourcertifiedtherapists: BrianReaksecker, PT CLT,ErinHirschler,OTR-LCLT,MegSablin-sky,PTCLT-LANA,andMelissaSmith,PTACLT.

WealsohavedevelopedaHeadandNeck Lymphedema ManagementProgram and we are working close-ly with Radonc and Surgery to see these patients as early as possible.Sometimes it will be only for a fewsessions,evaluating,educatingaboutwarning signs, decongestive exer-cises,rangeofmotionexercises,pos-ture,orsometimesmanuallymphaticdrainage when necessary. We are also trying to develop post-surgeryeducation handouts, in conjunctionwith Surgery.

Wealso have an increasing numberof early consults for patients withbreast cancer, which is quite suc-cessful sincemost of the time theyhaven’tdeveloppedlymphedemayetor it is at a very early stage. Thesepatientsreceiveeducationregardingwarning signs, decongestive exercis-es,activitiesofdailylife,manuallym-phaticdrainagewhenindicated,andsometimestheywillbefittedwithanappropriate compression garment.

Inallthecasesofoncologypatients,notonlydotheygetbetterwithtreat-ment, but they also feel somewhat reassured and feel support which is alsovery important.Theirqualityoflifeismuchimproved.

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Cancer Screening and Prevention2014PSHCSKristinGrady,ARNP,AOCN,NursePractitionerOncology

In 2014 the hospital performance measures for cancer screening haveremained within the target or havesteadilyimproved.Thebreastcancerscreening rate is at 88%, exceedingthe targetof 87.29%. The target forcervical cancer screening is 87.29%for all age groups and VA PugetSoundisat89.6%for21-65yearolds,and94.8% for21-29yearolds .Thecolorectal screening target was in-creased to 87.29% this year and al-though our screening at VA PSHCShas improved from 78% in 2013 to80.28% in 2014, we did not meetthis performance measure. Breast screeninghasimprovedoverthepastyearanditmeetingthemeetingthetargetat88%. Theoutpatientmea-sures for tobacco use are as follows: 1) the percentage of patients using

tobacco in the past year who havebeen offered medications to assistwithquittingsmokingis98%,exceed-ingourtargetof94.14%.2)Theper-centageofpatientsusingtobacco inthepastyearwhoareprovidedwithcounseling on how to quit is 98%,witha targetof94.15%.3)Theper-centageofpatientsusingtobacco inthepastyearwhoareofferedrefer-ral to a cessation program is 98%,exceeding the 94.15% target. Thesechanges demonstrate our hospital’s commitment to cancer screening and preventionandarejustafewoftheimprovements thatwere completedin 2014.Workingwith the VeteransreceivingcareatVAPugetSoundin-spiresustocontinuetostriveforex-cellence in Cancer Care.


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PalliativeCareandHospiceServiceReportLisaVigMDandDavidAGruenewaldMD

ThePalliativeCareandHospice Ser-vice (PCHS) continues to providecare for patients on both campusesofVAPSHCS.ThePalliativeCareSer-vicesaw585consults inFY14 (a7%increase from FY13), of which 29%werecancerpatients.PalliativeCaresaw 81% of all the Veterans whodied within our facility exceeded the EmergingMeasure 3 standard (55%of all inpatient deaths seen by theconsultationteamwithin12monthsprior to death). We also providedhospicereferralsto429Veteransandpaidfor44%ofthehospicecarepro-videdunderthesereferrals.

The consult service follows Veter-ansatboth theSeattle (SEA)andatAmerican Lake (AL) divisions. Thereare 10 hospice/palliative care bedsat the SEA Campus and 12 beds at AL.AnoutpatientclinicisavailableatALaswellas limitedhomevisits/in-homevestingvisitsinadefinedareaaroundtheALcampus.

The PCHS continues to engage ac-tively with our community partnersin theWe Honor Veterans program,sponsoredbytheDepartmentofVet-eransAffair in collaborationwith theNational Hospice and Palliative CareOrganization (NHPCO). The programinviteshospicesandstatehospiceor-ganizationsintoHospice-VeteranPart-nerships by recognizing the uniqueneedsofAmerica’sVeteransandtheirfamilies.ThePalliativeCare&Hospicestaffhasprovided in-servicesat indi-vidualcommunityhospices.AMilitaryHistory Checklist has been incorpo-rated into many hospices’ initial as-sessments, which has increased calls

to the PCHS as hospice programs seek waystoaccessVAbenefitsforVeter-ans in the community.

TheBereavedFamily Survey (BFS) isanationalVAfamilysatisfactionsur-vey administered by the PROMISECenterthatcontinuestomonitorthequality of end of life care for inpa-tientsatallVAmedical centers.Thenational campaign slogan is “Strivefor65”,whichreferstothegoalthat65% of bereaved family membersresponding to the BFS will rate the overall care the Veteran received attheendoflifeas“excellent”.Ourfa-cility’s performance on this indicator dropped from 67% in FY13 to 60%(slightlybetter than thenationalav-erageof59%) in thefirst3quartersofFY14,inconcertwithanationwidedecrease infamiliesreporting“over-all excellent” care during this time.Thismay reflect a change in surveymethodologyfromphonesurveystomail-insurveys.Predictorsassociated

withhigherBFSratings includedthepresence of a “Do Not Resuscitate”order,achaplainvisitwiththeVeter-anor familymember,palliativecareconsultation,andcareinadedicatedhospiceunit(i.e.,CLChospicebeds).

Palliativecareiscontinuingtocollab-oratewithourICUstoimprovepallia-tivecare inthe ICU,witha focusonimprovingthequalityandtimelinessof family meetings. A stakeholderworkgroupmeetsevery2weeksanda report to the Critical Care Com-mittee is planned soon. The work-group developed a family meetingnote template that allows the collec-tionofhealthfactorstotrackqualitymeasures for ICU family meetings,including which disciplines were rep-resented,thecodestatusoftheVet-eran before and after the meeting,and goals of care at the end of the meeting. We are continuing to de-velop nursing education approachestoempowernurses toparticipate in

themeetingsand to takea key roleinthe“4C’s”–Convening,Checking,Caring,andContinuing–referringtoessentialelementsofcommunicationinfamilymeetings.

The long term goal is to encourage these discussions to happen earlier in the course of care, which could re-sultinfewerVeteranswithcancerandother life-limiting illnesses receivingunwantedandinappropriateICU-levelinterventionsattheendoftheirlives.Wehavefoundthatasurprisingnum-ber of patients with terminal cancerare dying in the ICU. In a survey ofICUdeathsinQ3ofFY2013,17of27ICUdeathsoccurred inpatientswithterminal illnesses such asmetastaticcancer at the time of ICU admission(Dr. Vincent Fan, personal communi-cation).Thispresentsanopportunity

for collaboration between Oncology,ICUandPalliativeCare.

With this in mind, the PCHS has be-gun to see patients in the CancerCare Clinic who are identified bytheir Oncology providers as beingappropriatecandidatesforpalliativecare involvement (e.g., for goals ofcare discussions, symptom manage-ment support, family support, or other needs). Dr. Gruenewald re-cently met with Tamarind Keatingand Lynsi Slind (Cancer Care Navi-gators) to identifyways to improvethecoordinationofVeteransrequir-ing Cancer Care. With Ana Fisher MSWnow in theCancerCareNavi-gatorrole,PCHSanticipatesworkingcloselywith theNavigator programin the careofVeterans followedbybothservices.

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EnhancingcancercareservicesthroughWholeHealth-VA’sownmodelofpatient-centered,personalized,integrativecare.Dr.LeilaKozak,ClinicalChampionOPCC&CT,VAPSHCS

IntegrativeTherapiesarecomplemen-tary therapy interventions that havebeen shown to support healing and wellnessaswellasimprovesymptommanagement (particularly in cancercare).Integrativetherapiesareacoreresource in the implementation ofWholeHealth,theVA’sownmodelofpatient-centered,personalizedandin-tegrativecarenowrollingoutthrough-outVAfacilitiesnationally(seebelowformoreonWholeHealth).

Integrativetherapieshavean impor-tantroleincancerandpalliativecare,providing a wide range of benefits.HealingTouch,Touch/MassageTher-apies, Yoga, Tai Chi and meditationare evidence-based complementaryinterventions widely used in cancercare around the country and abroad. Because of their evidence-base indecreasing pain and anxiety and im-proving quality of life, they are in-creasinglyofferedtocancerpatientsand their families to improve symp-tom management.

The Whole Health approach to care includes thesemodalities as part ofthe wellness strategies that we need to make available for patients andfamilies needing support through cancer treatment and in palliativecare. Other modalities widely usedthat can be incorporated into cancer care include acupuncture, guided im-agery, hypnosis, music and art ther-apy, and animal-assisted therapies. Formore informationonhowotherVA facilities have embraced Whole

Health (including within cancer andpalliative care services) please visithttp://healthforlife.vacloud.us/index.php/research-education/education/

In addition to our current psycho-oncologyofferings(seearticleaboveby Dr. Aragon), one of the currentprograms we have at Puget SoundCancerCare is the “Touch,Caring&Cancer” (TCC) Program (www.part-nersinhealing.net).TCCwasoriginallytestedatVAPSHCSin2012-2013andresults from the study showed that Veterans and their caregivers werehighly satisfied with this program(Kozak et al, 2013). The study sug-gested that caregivers who learnedto provide massage benefited fromlearning the massage techniques,feeling more confident about theability to support their partner dur-ing cancer treatment and reportingan increased sense of closeness in their relationship thatwas nurturedby the massage practice. Thanks toOPCCfunding,VAPSHCShasreceivedcopies of this award-winning mul-timedia program and the DVD andmanual are currently available forfreetoanyVeteranandtheirspouse/caregiver atVAPuget SoundCancerCare through Oncology Social Work.

Integrative Therapy Tool-Kits for Whole-Health ImplementationLastyearwereportedonourprojectfunded at Puget Sound to developimplementation tool-kits forHealingTouch and Touch Therapies. Through thisprojectebroughttogether20VA

hospitals and CLCs from 5 differentVISNs.We are currently undergoingreview for the Healing Touch tool-kitandvideomaterials.TheHealingTouch Implementation Tool-Kit willhelp facilities learn how to designand implement their own Healing Touch services, including a “step bystepguide”toholdanin-houseHeal-ingTouchtraining,credentialingandbillingissues,scientificevidence,ed-ucationresources,andalltheforms,policiesandproceduresrequiredforimplementingHealingTouch.OneoftheHealing Touch videos (producedwithEES)thatwillbeavailableisa57Minute TMS course on Healing Touch thatwill provideCE credits forMDsandnursingprofessionals.Thisvideoexamines the role of Healing Touch as an integrative approach to Veteran-CenteredCare,theresearchevidenceand how it has been implemented at manyVAfacilities;andportraysVet-erans, staff and leadership perspec-tivesaboutHealingTouch.

A similar implementation tool-kitdeveloped for Touch Therapies in-cludes information from facilitiesthat have successfully implementedtouch/massage services, and guidesVA facilities that want to establishsimilar services.Twovideosarecur-rently undergoing final editing. Oneof the videos will be disseminatedas a TMS course, and will describe the experience of the first VA thathas implemented massage serviceswidelywithafull-timestaffLicensedMassage Therapist. It will also de-

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scribeavarietyofothertouch-basedprograms currently implemented at variousVAhospitalsandwillpresentVeterans, staff and leadership per-spectivesaboutTouchTherapies.Thesecondvideowillprovidetraining inbasic touch/massage skills for staffwho is interested in learning basic skills to include in their clinical work. Researchhasshownthatmultimediatrainingsareeffectivetoteachbasicandsafemassageskillstolaycaregiv-ers.Inthisvideoproduction,anexpe-rienced LicensedMassage TherapistattheVAAnnArborteachesstaffandvolunteershowtoprovidesafemas-sage in a hospital bed or in a chair, providing a great learning opportu-nitytoVAstaff.

Inadditiontothetool-kitswedevel-opedatPugetSound,Ihavebeenin-volved in collaborating with aWestLosAngelesVAteaminthedevelop-mentofother ImplementationTool-kits for Yoga, Tai Chi, Mindfulness(MBSR)andAromatherapy.WestLosAngeles VA as well as other facili-ties have been extremely successfulin delivering integrative therapies

acrossvariousservices.Forexample,West Los Angeles VA currently of-fers “Integrative Health and HealingConsults” across all services, andprovides 26 (yes, twenty six) yogaclasses a week including seated yoga forpalliativecareandyogaforcancerpatients. These tool-kits are amaz-ing resources as they have gleanedthewisdomfromfacilities thathavealreadyimplementedintegrativemo-dalitiessuccessfully,andwillbeavail-able to us shortly to design and im-plementourownintegrativetherapyservicesatPugetSound.

What is Whole Health and why it is relevant to cancer care?Big changes are happening nation-allywiththeofficialrollingoutoftheWholeHealthCurriculumdevelopedbytheOfficeofPatientCenteredCareand Cultural Transformation (OPCC&CT)atVACO.WholeHealthisVA’sownmodelofpatient-centeredcare,and it has been developed throughpartnerships with Planetree (www.planetree.org) and the Departmentof Integrative Medicine at the Uni-versityofWisconsin/Madison.These

national contracts with PlanetreeandUWMadisonhavehelpedtheVA systematize their approach todelivering Veteran-centered, per-sonalizedandintegrativecare.

AtthecoreofimplementingPCCiswhatwecall“changingtheconver-sation” from “What is the matterwithyou”to“Whatmatterstoyou?To “change the conversation,” weare using new tools developed byOPCC that help clinicians developa “personalized health plan” thatiscenteredoneachVeteran’sper-sonalvisionofhealth.Weusethe“ComponentsofPro-activeHealth&Well-Being”tohelptheVeteranbecomeawareofthedifferentareasthatmaybeaffectingtheirsenseofhealth and well-being and where they feel it is important to initiateaccording to their preferences and priorities (for more detailed infor-mationonthesetoolsyoucanvisitHealthforLife.vacloud.us/).

Throughthistransformativejourney,OPCC & CT is ensuring that all VAfacilities nationally shift intoWholeHealth through on-site and online staffeducation and resources avail-able to all. Puget Sound is quicklyadvancingimplementationofWholeHealththroughvariousmeans.InOc-tober 2014, more than 200 employ-eesattendedinpersonoronlinetheStaffEducationSessionstointroducethe facility to the Whole Health Cur-riculum andwewill be hosting theWhole Health Clinical Course for cli-niciansinJanuary2015.

Patient-centeredcare(PCC)iscarethatplacesthepatientatthecen-ter and considers thepatient as a



33

whole – as a physical, psychological, spiritual and social being. PCC implies changing the way we offer medicalcarebyemphasizingnotonlystateoftheartmedicalinterventionsbutalsofocusing on providing the best sup-portive environment that promoteshealing. This is usually referred to as enhancing the “patient experience.”The patient experience of care hasbeenshowntohavesuchan impacton healing outcomes that hospitals aroundthecountry(VAandnon-VA)areincreasinglyhiring“PatientExpe-rience Officer” to enhance the pa-tientexperiencearoundthefacility.

The“patientexperience”isnurturedby two core principles of PCC - Heal-ing Environments and Healing Rela-tionshipsaswellasintheintegrationof complementary therapies (“in-tegrative therapies”) that enhancewellness and provide psycho-social-spiritual support.

TheconceptofHealingEnvironmentsrefers to transforming the physical environment of care in a nurturing,supportive space that is conducivetohealing.HealingenvironmentsarecreatedthroughtheuseofEvidence-Based Architectural Design principles. “Evidence-Based Design” is a fieldthat emphasizes research evidenceto guide the design of healthcare spaces indoors and outdoors. Studies haveshownthatcertainarchitecturaldesign features can improvepatientand staff well-being, support heal-ing, promote stress reduction andenhance safety. For example, designs that incorporate natural light, colors, viewsofnatureandart installationshavebeenshowntopromotehealingandimproveoutcomesinhealthcare.The use of relaxing music and aroma-therapyhasbeenshownto improve

moodanddecreasestress/anxietyinpatientsaswellasemployees.

TheconceptofHealingRelationshipsrefers to creating relationships be-tween patient-provider and amongstaff that reflect trust, hope, and a“senseofbeingknown” (Scottetal,2008). Emotional self-management(emotionalintelligence)andmindful-nessarecompetenciesthathavebeenfound to be key facilitators in healing relationships.TheWholeHealthcur-riculum provides resources for staffto enhance awareness of emotionalself-management and mindfulness, sotheymaymodelthesetopatientsand in that manner, foster healing re-lationshipswithinhealthcare.

For Whole Health to take roots and provide its full benefits, everyoneinvolved in the health care systemneeds to have the skills to providesupportive, patient-centered, holisticcare. A welcoming smile or a helping hand, atrium space with live plantsor a view of themountains, a quietspace toprayormeditate,everyde-tailaffectsapatient’sexperienceandcontributesdirectly tohis/herhealthandwell-being.Healingenvironmentsandhealingrelationshipssupportpa-tients inovercoming their challengesandachievingtheirhealthgoals.Eachand every staff member who workswithinaVA facilityhasan impactonthepatient’sexperience.OPCCoffersan online Whole Health curriculum for all VA employees (not just clinicians)to learn how to incorporate PCC prin-ciplesintotheirdailyduties.Toaccessthis curriculum you can visit http://healthforlife.vacloud.us/index.php/research-education/education/.

As I continuemy work as a ClinicalChampion for OPCC now in my 4th

year,Ireflectontheexcitingopportu-nitiesthatwehaveatPugetSoundtocontinueleadingthewayintheinte-grationofWholeHealth into cancerandpalliativecare.

ReferencesKozakL,VigE,SimmonsC,EugenioE,CollingeW&ChapkoM.(2013)AFeasi-bilityStudyOfCaregiver-ProvidedMas-sageAsSupportiveCareInVACancerPatients. J. of Supportive Oncology,2013Aug [Epub ahead of print].

Scott JG, Cohen D, Dicicco-BloomB, Miller WL, Stange KC, CrabtreeBF. Understanding healing rela-tionships in primary care. Ann FamMed. 2008 Jul-Aug;6(4):315-22. doi:10.1370/afm.860. PubMed PMID:18626031; PubMedCentral. PMCID:PMC2478496.

Touch Caring & Cancer Program, availableathttp://partnersinhealing.net/index.htm AGuide to IntegrativeOncology forClinicians and Patients, available athttp://depts.washington.edu/in-tegonc/clinicians/about.shtml

Office of Patient-Centered Care &Culture Transformation website,available at http://healthforlife.va-cloud.us/

Office of Patient-Centered Care &Culture Transformation SharePointsite, available at http://vaww.infos-hare.va.gov/sites/OPCC/default.aspx

Whole Health curriculum may be accessed at http://healthforlife.va-cloud.us/index.php/research-educa-tion/education/

Enhancing cancer care services through Whole Health (Continued)

34

Spiritual CareChaplainGaryK.Cowden,BCC,ChiefofChaplainService

TheChaplainServiceoftheVAPugetSound Health Care System has been given theoverall spiritual careofallVA patients. Among our Veteransare those that experience the diag-nosis and treatment of cancer. At thetimeofapatient’sdiagnosisandtreatmentprojection,Chaplaincyen-deavors to support the patient andtheir family as they progress through thevarioustreatments,whetheritissurgery, chemotherapy, radiation,ora stem cell transplant. Spiritual sup-port covers both the negative andpositiveaspectsof cancer care suchastimesofwellnessandtimesofpal-liativeintervention.

Chaplainsareavailablewiththetreat-mentteamsasvariousspiritualneedssurface in the treatment process. Of-ten, along with the concerns of treat-ment symptoms, comes uncertainty, anxiety, fear of treatment outcomes, guilt, and spiritual distress. Through consults and various patient con-tacts,chaplainsgivespiritualsupportaffecting patient and familymorale.Chaplainshavealsobeeninvolvedinthe Tele-health program which brings caretopatientsintheirhome.

One aspect of care involves timeswhen treatment options becomelimited.PalliativeCarechaplaincyaf-fords opportunity to bring meaning and purpose to these times to helppatientsandtheir familiestransitionto a different perspective on theirtreatment goals. Chaplains havegiven consistent and positive sup-port through this process. When the limitations of science lead a patienttoward another destiny, Chaplains

arepreparedtogivespiritualsupportthrough these un-charted experienc-estoboththepatientandthefami-lies surrounding them.

Finally,Chaplainsbringbereavementcare to patients and families in thejourneyoffinishingtheirtimeoflife.Memorial services are held twice ayear for all patientswhohave beenin the hospital at their end of life. Theirfamiliesareinvitedtoattendasa way of celebrating their memory.Each family is invited to attend andto bring pictures and memorabilia that helps share their memory with others. The Hospital Director and variousstaffmembersare invitedtoshare the experience. Family mem-bersare invited toshare their lovedones experience. Many of the stories of support by the VA Hospital giveoverwhelmingcredibilitytotheCan-cer program .


1660 S. Columbian WaySeattle,WA98108Phone:206.764.2934Fax:206.764.2851

CREDITS

EditingConsultants

Sudarshana Das, CTR, RHITAlisa Engeland

Graphic Design

Alisa Engeland

ArticleContributors

Dawn Irene Aragon, PhD LeahBackhus,MD,withMichaelS.Mulligan,MD,and Thomas McDonough, PA-CJeannine Barton with Stephanie MagoneCathyBlanchard,LICSW,OSW-CwithAnaFisher,LICSW,OSW-CVictoriaCampaThomas R. Chauncey, MD, PhDMarc D Coltrera, MD with Isaac Bohannon, MD andJeffreyHoulton,MDGary K. Cowden, BCCSudarshana Das, B.Com, CTR, RHITYesheargDagne,BSN,RN,OCNAnaFisher,LICSWandCathyBlanchard,LICSWKristinGrady,ARNP,AOCNDavidAGrunewald,MD,andLisaVig,MDLeilaKozak,PhDMichael P. Porter, MD with R. Bruce Montgomery, MDMelissa Powell, RD withWing Yan (Venus) Ng,RD, CNSCTony S. Quang, MD, and Kent Wallner, MDJoseph G Rajendran, MD, and Julie Takasugi, MDMargaretSablinsky,PT,DPT,CLT-LANALynsiSlind,RN,MNwithTamarindKeating,ARNP,JesusRivera,PSA,AnaFisher,LICSWOSW-CDanielY.Wu,MD,PhDPeterC.Wu,MD(CancerCommitteeChair)

cancer program annual report · 2018-05-03 · cancer program annual report 3 cancer registry...

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