Hospice & Palliative Medicine

Background: Colorectal cancer screening through colonoscopy has long been recognized as the gold standard in detecting precancerous lesions. Approximately 40% to 50% of asymptomatic individuals undergoing screening colonoscopy will have at least 1 polyp removed, and 20% of individuals have multiple polyps removed. Genetic testing for polyposis was initially evaluated in high-risk families. Therefore, prior to January 2015, the National Comprehensive Cancer Network (NCCN) guidelines recommended any individual with > 10 lifetime adenomas be referred for genetic counseling and possible genetic testing. Revised guidelines increased the suggested number of adenomas required for testing from 10 to 20.The NCCN guidelines stipulate ordering of APC and/or MUTYH gene testing at the discretion of the clinician. Assessment prior to testing should include eliciting a family history and other lifestyle factors. Several risk factors associated with increased polyp burden include age, gender, smoking, body mass index, and diet. In addition, there is little guidance for situations in which genetic testing is unlikely to be informative or change management. Despite this, there are few data to suggest testing may have low utility for individuals with multiple risk factors that are the more likely cause of polyposis. Considering many veterans are smokers and have other risk factors, the VHA is in a unique position to assess the utility of genetic testing for inherited polyposis in a general population screening setting.

Purpose: To describe the characteristics of veterans with more than 10 adenomas who were tested for APC and MUTYH mutations and determine the frequency of mutations.

Methods: Retrospective chart review of individuals who had counseling and genetic testing for APC/MUTYH through the Genomic Medicine Service. Veterans were excluded if they presented for reasons other than routine colon screening or surveillance.

Results: Five out of 81 (6%) veterans who met inclusion criteria had a pathogenic mutation in APC or 2 pathogenic mutations in MUTYH. Only 1 of those individuals had fewer than 20 adenomas prior to testing.

Conclusions: Our results support the recent revisions to NCCN testing guidelines. Our experience suggests the need for integration of other factors into risk assessment beyond total number of adenomas detected, including known risk factors and age at first colonoscopy.

Background: Colorectal cancer screening through colonoscopy has long been recognized as the gold standard in detecting precancerous lesions. Approximately 40% to 50% of asymptomatic individuals undergoing screening colonoscopy will have at least 1 polyp removed, and 20% of individuals have multiple polyps removed. Genetic testing for polyposis was initially evaluated in high-risk families. Therefore, prior to January 2015, the National Comprehensive Cancer Network (NCCN) guidelines recommended any individual with > 10 lifetime adenomas be referred for genetic counseling and possible genetic testing. Revised guidelines increased the suggested number of adenomas required for testing from 10 to 20.The NCCN guidelines stipulate ordering of APC and/or MUTYH gene testing at the discretion of the clinician. Assessment prior to testing should include eliciting a family history and other lifestyle factors. Several risk factors associated with increased polyp burden include age, gender, smoking, body mass index, and diet. In addition, there is little guidance for situations in which genetic testing is unlikely to be informative or change management. Despite this, there are few data to suggest testing may have low utility for individuals with multiple risk factors that are the more likely cause of polyposis. Considering many veterans are smokers and have other risk factors, the VHA is in a unique position to assess the utility of genetic testing for inherited polyposis in a general population screening setting.

Purpose: To describe the characteristics of veterans with more than 10 adenomas who were tested for APC and MUTYH mutations and determine the frequency of mutations.

Methods: Retrospective chart review of individuals who had counseling and genetic testing for APC/MUTYH through the Genomic Medicine Service. Veterans were excluded if they presented for reasons other than routine colon screening or surveillance.

Results: Five out of 81 (6%) veterans who met inclusion criteria had a pathogenic mutation in APC or 2 pathogenic mutations in MUTYH. Only 1 of those individuals had fewer than 20 adenomas prior to testing.

Conclusions: Our results support the recent revisions to NCCN testing guidelines. Our experience suggests the need for integration of other factors into risk assessment beyond total number of adenomas detected, including known risk factors and age at first colonoscopy.

Background: Colorectal cancer screening through colonoscopy has long been recognized as the gold standard in detecting precancerous lesions. Approximately 40% to 50% of asymptomatic individuals undergoing screening colonoscopy will have at least 1 polyp removed, and 20% of individuals have multiple polyps removed. Genetic testing for polyposis was initially evaluated in high-risk families. Therefore, prior to January 2015, the National Comprehensive Cancer Network (NCCN) guidelines recommended any individual with > 10 lifetime adenomas be referred for genetic counseling and possible genetic testing. Revised guidelines increased the suggested number of adenomas required for testing from 10 to 20.The NCCN guidelines stipulate ordering of APC and/or MUTYH gene testing at the discretion of the clinician. Assessment prior to testing should include eliciting a family history and other lifestyle factors. Several risk factors associated with increased polyp burden include age, gender, smoking, body mass index, and diet. In addition, there is little guidance for situations in which genetic testing is unlikely to be informative or change management. Despite this, there are few data to suggest testing may have low utility for individuals with multiple risk factors that are the more likely cause of polyposis. Considering many veterans are smokers and have other risk factors, the VHA is in a unique position to assess the utility of genetic testing for inherited polyposis in a general population screening setting.

Purpose: To describe the characteristics of veterans with more than 10 adenomas who were tested for APC and MUTYH mutations and determine the frequency of mutations.

Methods: Retrospective chart review of individuals who had counseling and genetic testing for APC/MUTYH through the Genomic Medicine Service. Veterans were excluded if they presented for reasons other than routine colon screening or surveillance.

Results: Five out of 81 (6%) veterans who met inclusion criteria had a pathogenic mutation in APC or 2 pathogenic mutations in MUTYH. Only 1 of those individuals had fewer than 20 adenomas prior to testing.

Conclusions: Our results support the recent revisions to NCCN testing guidelines. Our experience suggests the need for integration of other factors into risk assessment beyond total number of adenomas detected, including known risk factors and age at first colonoscopy.

Background: The VA Puget Sound Health Care System (VAPSHCS) is a referral center for cancer care of veterans in Washington, Idaho, Oregon, and Alaska. Travel burden poses a significant barrier, putting veterans at high risk for delays in care. Nearly 50% of veterans seen in oncology at the VAPSHCS in 2012 and 2013 traveled 50 miles or more, and 25% came from out of state. A VISN 20 pilot program was established, consisting of multidisciplinary Cancer Care Navigation Teams (CCNTs) at 8 sites across the VISN to address and reduce barriers for these veterans. At VAPSHCS, a nurse practitioner, registered nurse, social worker, and program assistant comprise the CCNT. A clear transition process was developed to ensure timely cancer care and prevent veterans from getting lost in the cancer continuum.

Purpose: Identify and implement processes for patient navigation for veterans traveling for cancer care.

Methods: Navigation processes were identified based on a local needs assessment and review of cancer navigation literature. Veteran identification, assessment, education, and care team coordination processes were established and modified over time according to veteran and provider feedback.

Results: Veterans are identified through pathology results, tumor board, or consult from medical providers or referring facilities. During the veteran’s initial visit, an intake evaluation is completed to identify barriers to care. A distress screening and functional assessment are also documented at this time, and a plan is put into place to address identified concerns. Veterans are educated about their diagnosis and treatment and receive an orientation to the facility. During treatment, weekly chart reviews and patient call rounds are conducted with CCNTs at referring facilities. At the conclusion of treatment, a written treatment summary with follow-up recommendations is given to the veteran and documented in the medical record. Since October 2014, the VAPSHCS CCNT has provided navigation services to 345 veterans with the tracking of > 1,300 appointments, 360 trips, and has made over 350 referrals to other services.

Implications: We present a multidisciplinary navigation team model that may be adopted to address barriers of veterans who must travel for cancer care.

Background: The VA Puget Sound Health Care System (VAPSHCS) is a referral center for cancer care of veterans in Washington, Idaho, Oregon, and Alaska. Travel burden poses a significant barrier, putting veterans at high risk for delays in care. Nearly 50% of veterans seen in oncology at the VAPSHCS in 2012 and 2013 traveled 50 miles or more, and 25% came from out of state. A VISN 20 pilot program was established, consisting of multidisciplinary Cancer Care Navigation Teams (CCNTs) at 8 sites across the VISN to address and reduce barriers for these veterans. At VAPSHCS, a nurse practitioner, registered nurse, social worker, and program assistant comprise the CCNT. A clear transition process was developed to ensure timely cancer care and prevent veterans from getting lost in the cancer continuum.

Purpose: Identify and implement processes for patient navigation for veterans traveling for cancer care.

Methods: Navigation processes were identified based on a local needs assessment and review of cancer navigation literature. Veteran identification, assessment, education, and care team coordination processes were established and modified over time according to veteran and provider feedback.

Results: Veterans are identified through pathology results, tumor board, or consult from medical providers or referring facilities. During the veteran’s initial visit, an intake evaluation is completed to identify barriers to care. A distress screening and functional assessment are also documented at this time, and a plan is put into place to address identified concerns. Veterans are educated about their diagnosis and treatment and receive an orientation to the facility. During treatment, weekly chart reviews and patient call rounds are conducted with CCNTs at referring facilities. At the conclusion of treatment, a written treatment summary with follow-up recommendations is given to the veteran and documented in the medical record. Since October 2014, the VAPSHCS CCNT has provided navigation services to 345 veterans with the tracking of > 1,300 appointments, 360 trips, and has made over 350 referrals to other services.

Implications: We present a multidisciplinary navigation team model that may be adopted to address barriers of veterans who must travel for cancer care.

Background: The VA Puget Sound Health Care System (VAPSHCS) is a referral center for cancer care of veterans in Washington, Idaho, Oregon, and Alaska. Travel burden poses a significant barrier, putting veterans at high risk for delays in care. Nearly 50% of veterans seen in oncology at the VAPSHCS in 2012 and 2013 traveled 50 miles or more, and 25% came from out of state. A VISN 20 pilot program was established, consisting of multidisciplinary Cancer Care Navigation Teams (CCNTs) at 8 sites across the VISN to address and reduce barriers for these veterans. At VAPSHCS, a nurse practitioner, registered nurse, social worker, and program assistant comprise the CCNT. A clear transition process was developed to ensure timely cancer care and prevent veterans from getting lost in the cancer continuum.

Purpose: Identify and implement processes for patient navigation for veterans traveling for cancer care.

Methods: Navigation processes were identified based on a local needs assessment and review of cancer navigation literature. Veteran identification, assessment, education, and care team coordination processes were established and modified over time according to veteran and provider feedback.

Results: Veterans are identified through pathology results, tumor board, or consult from medical providers or referring facilities. During the veteran’s initial visit, an intake evaluation is completed to identify barriers to care. A distress screening and functional assessment are also documented at this time, and a plan is put into place to address identified concerns. Veterans are educated about their diagnosis and treatment and receive an orientation to the facility. During treatment, weekly chart reviews and patient call rounds are conducted with CCNTs at referring facilities. At the conclusion of treatment, a written treatment summary with follow-up recommendations is given to the veteran and documented in the medical record. Since October 2014, the VAPSHCS CCNT has provided navigation services to 345 veterans with the tracking of > 1,300 appointments, 360 trips, and has made over 350 referrals to other services.

Implications: We present a multidisciplinary navigation team model that may be adopted to address barriers of veterans who must travel for cancer care.

Purpose: The purpose of the study is to determine the effect of aromatherapy on anxiety for patients receiving their first series of radiation therapy to the upper chest, neck, and/or head.

Background: For patients with head and neck, lung, or brain cancer, radiation therapy is a primary treatment and involves using a restraining device over the upper body during therapy. This procedure has the capacity to produce anxiety for anyone receiving this treatment. It can be even more anxiety producing for veterans with posttraumatic stress disorder or histories of active-duty-related trauma. Current management of anxiety includes anti-anxiety pharmaceuticals, calming music, and behavior therapy. Anti-anxiety medications, although helpful, have adverse effects and potential for dependence. They may also interfere with travel for patients who drive themselves back and forth from treatment. Some essential oils used in aromatherapy are known to have anti-anxiety properties. Radiation therapy would seem to be uniquely suited for using this approach of reducing anxiety.

Methods: This pilot study will include a total of 10 patients. In this large Midwestern VA academic medical center, about 10 to 15 new patients with head, neck, lung, or brain cancers are seen per month. It is expected this pilot can be concluded in 1 to 2 months. The aromatherapy intervention will incorporate a commercial product using 2 combinations of essential oils to reduce anxiety: (1) orange-peppermint and (2) lavender-sandalwood. Two instruments will be used to measure anxiety: a visual analog scale of 0 to 10 for anxiety as reported by patients and a symptom checklist for anxiety as observed by clinicians.

Data Analysis: Descriptive statistics and qualitative patients comments will be used to describe results.

Conclusions: This pilot study tests the feasibility of using aromatherapy in radiation oncology. This study provides a basis for a research project investigating the effectiveness of specific essential oils vs standard symptom management to reduce anxiety in radiation therapy.

Purpose: The purpose of the study is to determine the effect of aromatherapy on anxiety for patients receiving their first series of radiation therapy to the upper chest, neck, and/or head.

Background: For patients with head and neck, lung, or brain cancer, radiation therapy is a primary treatment and involves using a restraining device over the upper body during therapy. This procedure has the capacity to produce anxiety for anyone receiving this treatment. It can be even more anxiety producing for veterans with posttraumatic stress disorder or histories of active-duty-related trauma. Current management of anxiety includes anti-anxiety pharmaceuticals, calming music, and behavior therapy. Anti-anxiety medications, although helpful, have adverse effects and potential for dependence. They may also interfere with travel for patients who drive themselves back and forth from treatment. Some essential oils used in aromatherapy are known to have anti-anxiety properties. Radiation therapy would seem to be uniquely suited for using this approach of reducing anxiety.

Methods: This pilot study will include a total of 10 patients. In this large Midwestern VA academic medical center, about 10 to 15 new patients with head, neck, lung, or brain cancers are seen per month. It is expected this pilot can be concluded in 1 to 2 months. The aromatherapy intervention will incorporate a commercial product using 2 combinations of essential oils to reduce anxiety: (1) orange-peppermint and (2) lavender-sandalwood. Two instruments will be used to measure anxiety: a visual analog scale of 0 to 10 for anxiety as reported by patients and a symptom checklist for anxiety as observed by clinicians.

Data Analysis: Descriptive statistics and qualitative patients comments will be used to describe results.

Conclusions: This pilot study tests the feasibility of using aromatherapy in radiation oncology. This study provides a basis for a research project investigating the effectiveness of specific essential oils vs standard symptom management to reduce anxiety in radiation therapy.

Purpose: The purpose of the study is to determine the effect of aromatherapy on anxiety for patients receiving their first series of radiation therapy to the upper chest, neck, and/or head.

Background: For patients with head and neck, lung, or brain cancer, radiation therapy is a primary treatment and involves using a restraining device over the upper body during therapy. This procedure has the capacity to produce anxiety for anyone receiving this treatment. It can be even more anxiety producing for veterans with posttraumatic stress disorder or histories of active-duty-related trauma. Current management of anxiety includes anti-anxiety pharmaceuticals, calming music, and behavior therapy. Anti-anxiety medications, although helpful, have adverse effects and potential for dependence. They may also interfere with travel for patients who drive themselves back and forth from treatment. Some essential oils used in aromatherapy are known to have anti-anxiety properties. Radiation therapy would seem to be uniquely suited for using this approach of reducing anxiety.

Methods: This pilot study will include a total of 10 patients. In this large Midwestern VA academic medical center, about 10 to 15 new patients with head, neck, lung, or brain cancers are seen per month. It is expected this pilot can be concluded in 1 to 2 months. The aromatherapy intervention will incorporate a commercial product using 2 combinations of essential oils to reduce anxiety: (1) orange-peppermint and (2) lavender-sandalwood. Two instruments will be used to measure anxiety: a visual analog scale of 0 to 10 for anxiety as reported by patients and a symptom checklist for anxiety as observed by clinicians.

Data Analysis: Descriptive statistics and qualitative patients comments will be used to describe results.

Conclusions: This pilot study tests the feasibility of using aromatherapy in radiation oncology. This study provides a basis for a research project investigating the effectiveness of specific essential oils vs standard symptom management to reduce anxiety in radiation therapy.

Background: Mindfulness-based approaches have been found to be beneficial for patients with cancer. Research has found improvements in sleep, depression, anxiety, and general distress among patients with cancer. This presentation will describe the development and implementation of an 8-week mindfulness group. Veterans at any stage of cancer treatment were eligible to participate and were provided the opportunity to invite a family member or caregiver. The groups were facilitated by 2 psychologists. Participants were recruited in the chemotherapy room and by referral from 2 oncologists. Recruitment challenges included the following issues: the distance the individual lived from the VA facility, other commitments that conflicted with the date and time of the group lack of transportation, or the perception that the individual did not need the services. In addition, mental illness stigma was a factor, as some individuals indicated a reluctance to receive services associated with psychology.

Methods: The weekly group sessions were structured in the following manner: check in/socialization, mindfulness practice, and assignment of out-of-session practice. The check in/ socialization provided an opportunity to assess participants’ home practice, note successes, and address barriers to mindfulness practice at home. In addition, the check in/socialization served to foster peer support and group cohesion as participants shared their perspectives and provided suggestions and encouraging feedback to one another. This aspect of the group also provided opportunities for participants to relate their cancer treatment experience (eg, pain, fatigue, physical discomfort, treatment impact on physical appearance, and intimate relationships) to the practice of mindfulness.

Mindfulness practice included exercises focusing on the mindfulness skills of nonjudgmental observing/noticing, accepting/allowing, and self-compassion. Specifically, participants mindfully attended to the breath, body sensations, and awareness of their physical environment in the present moment. In addition, participants engaged in mindful eating. Out-of-session practice was assigned weekly and participants were asked to practice at home the skills they learned in group and report on their progress during the next session.

Conclusions: The presentation provides the nature of the collaboration between the cancer team and mental health services and recommendations for promoting success at other facilities.

Background: Mindfulness-based approaches have been found to be beneficial for patients with cancer. Research has found improvements in sleep, depression, anxiety, and general distress among patients with cancer. This presentation will describe the development and implementation of an 8-week mindfulness group. Veterans at any stage of cancer treatment were eligible to participate and were provided the opportunity to invite a family member or caregiver. The groups were facilitated by 2 psychologists. Participants were recruited in the chemotherapy room and by referral from 2 oncologists. Recruitment challenges included the following issues: the distance the individual lived from the VA facility, other commitments that conflicted with the date and time of the group lack of transportation, or the perception that the individual did not need the services. In addition, mental illness stigma was a factor, as some individuals indicated a reluctance to receive services associated with psychology.

Methods: The weekly group sessions were structured in the following manner: check in/socialization, mindfulness practice, and assignment of out-of-session practice. The check in/ socialization provided an opportunity to assess participants’ home practice, note successes, and address barriers to mindfulness practice at home. In addition, the check in/socialization served to foster peer support and group cohesion as participants shared their perspectives and provided suggestions and encouraging feedback to one another. This aspect of the group also provided opportunities for participants to relate their cancer treatment experience (eg, pain, fatigue, physical discomfort, treatment impact on physical appearance, and intimate relationships) to the practice of mindfulness.

Mindfulness practice included exercises focusing on the mindfulness skills of nonjudgmental observing/noticing, accepting/allowing, and self-compassion. Specifically, participants mindfully attended to the breath, body sensations, and awareness of their physical environment in the present moment. In addition, participants engaged in mindful eating. Out-of-session practice was assigned weekly and participants were asked to practice at home the skills they learned in group and report on their progress during the next session.

Conclusions: The presentation provides the nature of the collaboration between the cancer team and mental health services and recommendations for promoting success at other facilities.

Background: Mindfulness-based approaches have been found to be beneficial for patients with cancer. Research has found improvements in sleep, depression, anxiety, and general distress among patients with cancer. This presentation will describe the development and implementation of an 8-week mindfulness group. Veterans at any stage of cancer treatment were eligible to participate and were provided the opportunity to invite a family member or caregiver. The groups were facilitated by 2 psychologists. Participants were recruited in the chemotherapy room and by referral from 2 oncologists. Recruitment challenges included the following issues: the distance the individual lived from the VA facility, other commitments that conflicted with the date and time of the group lack of transportation, or the perception that the individual did not need the services. In addition, mental illness stigma was a factor, as some individuals indicated a reluctance to receive services associated with psychology.

Methods: The weekly group sessions were structured in the following manner: check in/socialization, mindfulness practice, and assignment of out-of-session practice. The check in/ socialization provided an opportunity to assess participants’ home practice, note successes, and address barriers to mindfulness practice at home. In addition, the check in/socialization served to foster peer support and group cohesion as participants shared their perspectives and provided suggestions and encouraging feedback to one another. This aspect of the group also provided opportunities for participants to relate their cancer treatment experience (eg, pain, fatigue, physical discomfort, treatment impact on physical appearance, and intimate relationships) to the practice of mindfulness.

Mindfulness practice included exercises focusing on the mindfulness skills of nonjudgmental observing/noticing, accepting/allowing, and self-compassion. Specifically, participants mindfully attended to the breath, body sensations, and awareness of their physical environment in the present moment. In addition, participants engaged in mindful eating. Out-of-session practice was assigned weekly and participants were asked to practice at home the skills they learned in group and report on their progress during the next session.

Conclusions: The presentation provides the nature of the collaboration between the cancer team and mental health services and recommendations for promoting success at other facilities.

Purpose: To improve access to care for patients with cancer by identifying and implementing a process for nononcology nurses to provide regional care to remote cancer patients.

Background: The Cleveland VA Medical Center (CVAMC) provides yearly care to more than 105,000 veterans and diagnoses and treats nearly 800 new cancer patients each year. The CVAMC has 13 community-based outpatient clinics (CBOCs) covering 24 counties with only 3 located within 40 miles of the CVAMC. The average distance to this facility from all CBOCs is 66 miles.

Methods: A multidisciplinary group of 8 leaders gathered in 2014 to identify services that might be offered at regional CBOCs following the training of the nurses in accessing implanted ports, safely administering leuprolide, and disconnecting a chemotherapy ambulatory infusion pump. (During this time, a pilot was in progress of a disposable elastomeric ambulatory pump to replace the chemo bag/mechanical pump system.)

Data Analysis: In 2013, nurses identified a need for improved patient access when a small study was done (n = 71) looking at the distance traveled to have an implanted port flushed. It showed that 48% had traveled > 20 miles. In 2014, better defined by the Access to Care initiative, an expanded review was done, and 4 interspersed CBOCs were identified that might improve access to care for veterans living > 40 miles from the CVAMC.

Results: In 2014, nurses from 6 CBOCs were educated on the safe mixing, administering, and disposal of leuprolide. On June 1, 2015, mechanical ambulatory pumps were replaced by disposable elastomeric pumps. On June 10, 4 volunteers from each of the 4 CBOCs began clinical training on accessing implanted ports, doing central-line lab draws, flushing/ heparinizing implanted ports, disconnecting the elastomeric pump, and appropriate disposal. The completed training is projected for August 21, 2015, with full implementation of regional care to begin August 28, 2015.

Conclusions: A small nursing initiative, fueled by a national goal, can generate multidisciplinary interest and insights in effectively implementing an evidence-based process that offers cancer patients regional care. The full impact will be disclosed at the AVAHO annual meeting.

Purpose: To improve access to care for patients with cancer by identifying and implementing a process for nononcology nurses to provide regional care to remote cancer patients.

Background: The Cleveland VA Medical Center (CVAMC) provides yearly care to more than 105,000 veterans and diagnoses and treats nearly 800 new cancer patients each year. The CVAMC has 13 community-based outpatient clinics (CBOCs) covering 24 counties with only 3 located within 40 miles of the CVAMC. The average distance to this facility from all CBOCs is 66 miles.

Methods: A multidisciplinary group of 8 leaders gathered in 2014 to identify services that might be offered at regional CBOCs following the training of the nurses in accessing implanted ports, safely administering leuprolide, and disconnecting a chemotherapy ambulatory infusion pump. (During this time, a pilot was in progress of a disposable elastomeric ambulatory pump to replace the chemo bag/mechanical pump system.)

Data Analysis: In 2013, nurses identified a need for improved patient access when a small study was done (n = 71) looking at the distance traveled to have an implanted port flushed. It showed that 48% had traveled > 20 miles. In 2014, better defined by the Access to Care initiative, an expanded review was done, and 4 interspersed CBOCs were identified that might improve access to care for veterans living > 40 miles from the CVAMC.

Results: In 2014, nurses from 6 CBOCs were educated on the safe mixing, administering, and disposal of leuprolide. On June 1, 2015, mechanical ambulatory pumps were replaced by disposable elastomeric pumps. On June 10, 4 volunteers from each of the 4 CBOCs began clinical training on accessing implanted ports, doing central-line lab draws, flushing/ heparinizing implanted ports, disconnecting the elastomeric pump, and appropriate disposal. The completed training is projected for August 21, 2015, with full implementation of regional care to begin August 28, 2015.

Conclusions: A small nursing initiative, fueled by a national goal, can generate multidisciplinary interest and insights in effectively implementing an evidence-based process that offers cancer patients regional care. The full impact will be disclosed at the AVAHO annual meeting.

Purpose: To improve access to care for patients with cancer by identifying and implementing a process for nononcology nurses to provide regional care to remote cancer patients.

Background: The Cleveland VA Medical Center (CVAMC) provides yearly care to more than 105,000 veterans and diagnoses and treats nearly 800 new cancer patients each year. The CVAMC has 13 community-based outpatient clinics (CBOCs) covering 24 counties with only 3 located within 40 miles of the CVAMC. The average distance to this facility from all CBOCs is 66 miles.

Methods: A multidisciplinary group of 8 leaders gathered in 2014 to identify services that might be offered at regional CBOCs following the training of the nurses in accessing implanted ports, safely administering leuprolide, and disconnecting a chemotherapy ambulatory infusion pump. (During this time, a pilot was in progress of a disposable elastomeric ambulatory pump to replace the chemo bag/mechanical pump system.)

Data Analysis: In 2013, nurses identified a need for improved patient access when a small study was done (n = 71) looking at the distance traveled to have an implanted port flushed. It showed that 48% had traveled > 20 miles. In 2014, better defined by the Access to Care initiative, an expanded review was done, and 4 interspersed CBOCs were identified that might improve access to care for veterans living > 40 miles from the CVAMC.

Results: In 2014, nurses from 6 CBOCs were educated on the safe mixing, administering, and disposal of leuprolide. On June 1, 2015, mechanical ambulatory pumps were replaced by disposable elastomeric pumps. On June 10, 4 volunteers from each of the 4 CBOCs began clinical training on accessing implanted ports, doing central-line lab draws, flushing/ heparinizing implanted ports, disconnecting the elastomeric pump, and appropriate disposal. The completed training is projected for August 21, 2015, with full implementation of regional care to begin August 28, 2015.

Conclusions: A small nursing initiative, fueled by a national goal, can generate multidisciplinary interest and insights in effectively implementing an evidence-based process that offers cancer patients regional care. The full impact will be disclosed at the AVAHO annual meeting.

Background: Significant progress has been achieved within the past decade to support novel, personalized disease-targeted drug development in oncology. The development of radiopharmaceutical-based molecular imaging biomarkers and therapeutics requires significant infrastructure to support the necessary basic science investigations for both in vitro and in vivo preclinical investigative new drug supportive studies, including USP compliant radiopharmaceutical formulation. The Harry S. Truman Memorial Veterans’ Hospital is engaged in conducting bench to bedside translation of novel theranostic (therapeutic and diagnostic) radiopharmaceuticals with the goal of supporting a wide range of physician-sponsored phase 1 clinical oncology trials.

Methods: As examples, we have used a combination of commercial chemical synthesis and in-house automated solid phase peptide synthesis to generate peptide vectors targeting the somatostatin and bombesin receptor systems. Automated radiochemical synthesis of Ga-68 products for diagnostic positron emission tomography (PET) imaging and Lu-177 products for targeted radiotherapeutic applications has been accomplished. The resulting radiolabeled products were validated in vitro, using a combination of cell-based assays assessing receptor-binding affinity, cell proliferation, and flow cytometry. Preclinical animal-based screening assays included validating tumor targeting capability by evaluating in vivo drug pharmacokinetics, assessing therapeutic efficacy in human tumor xenografted rodent models, and preclinical molecular imaging of radiopharmaceutical localization employing PET, single-photon emission computed tomography, computed tomography, and MRI. The FDA IND supportive studies to demonstrate routine drug production capability and product reproducibility are accomplished by using commercial automated radiochemical synthesis technology.

Results: Multiple Ga-68- and Lu-177-labeled radiopharmaceuticals have now been produced and tested in vitro and in vivo, using appropriate preclinical models of prostate and breast cancer. Routine data collection for validation of radiopharmaceutical reproducibility is ongoing.

Conclusion: This presentation outlines the resources necessary and validates the steps required to establish a translational radiopharmaceutical research and production facility for the in-house preparation of novel oncology-directed biomarkers and targeted therapeutics.

Background: Significant progress has been achieved within the past decade to support novel, personalized disease-targeted drug development in oncology. The development of radiopharmaceutical-based molecular imaging biomarkers and therapeutics requires significant infrastructure to support the necessary basic science investigations for both in vitro and in vivo preclinical investigative new drug supportive studies, including USP compliant radiopharmaceutical formulation. The Harry S. Truman Memorial Veterans’ Hospital is engaged in conducting bench to bedside translation of novel theranostic (therapeutic and diagnostic) radiopharmaceuticals with the goal of supporting a wide range of physician-sponsored phase 1 clinical oncology trials.

Methods: As examples, we have used a combination of commercial chemical synthesis and in-house automated solid phase peptide synthesis to generate peptide vectors targeting the somatostatin and bombesin receptor systems. Automated radiochemical synthesis of Ga-68 products for diagnostic positron emission tomography (PET) imaging and Lu-177 products for targeted radiotherapeutic applications has been accomplished. The resulting radiolabeled products were validated in vitro, using a combination of cell-based assays assessing receptor-binding affinity, cell proliferation, and flow cytometry. Preclinical animal-based screening assays included validating tumor targeting capability by evaluating in vivo drug pharmacokinetics, assessing therapeutic efficacy in human tumor xenografted rodent models, and preclinical molecular imaging of radiopharmaceutical localization employing PET, single-photon emission computed tomography, computed tomography, and MRI. The FDA IND supportive studies to demonstrate routine drug production capability and product reproducibility are accomplished by using commercial automated radiochemical synthesis technology.

Results: Multiple Ga-68- and Lu-177-labeled radiopharmaceuticals have now been produced and tested in vitro and in vivo, using appropriate preclinical models of prostate and breast cancer. Routine data collection for validation of radiopharmaceutical reproducibility is ongoing.

Conclusion: This presentation outlines the resources necessary and validates the steps required to establish a translational radiopharmaceutical research and production facility for the in-house preparation of novel oncology-directed biomarkers and targeted therapeutics.

Background: Significant progress has been achieved within the past decade to support novel, personalized disease-targeted drug development in oncology. The development of radiopharmaceutical-based molecular imaging biomarkers and therapeutics requires significant infrastructure to support the necessary basic science investigations for both in vitro and in vivo preclinical investigative new drug supportive studies, including USP compliant radiopharmaceutical formulation. The Harry S. Truman Memorial Veterans’ Hospital is engaged in conducting bench to bedside translation of novel theranostic (therapeutic and diagnostic) radiopharmaceuticals with the goal of supporting a wide range of physician-sponsored phase 1 clinical oncology trials.

Methods: As examples, we have used a combination of commercial chemical synthesis and in-house automated solid phase peptide synthesis to generate peptide vectors targeting the somatostatin and bombesin receptor systems. Automated radiochemical synthesis of Ga-68 products for diagnostic positron emission tomography (PET) imaging and Lu-177 products for targeted radiotherapeutic applications has been accomplished. The resulting radiolabeled products were validated in vitro, using a combination of cell-based assays assessing receptor-binding affinity, cell proliferation, and flow cytometry. Preclinical animal-based screening assays included validating tumor targeting capability by evaluating in vivo drug pharmacokinetics, assessing therapeutic efficacy in human tumor xenografted rodent models, and preclinical molecular imaging of radiopharmaceutical localization employing PET, single-photon emission computed tomography, computed tomography, and MRI. The FDA IND supportive studies to demonstrate routine drug production capability and product reproducibility are accomplished by using commercial automated radiochemical synthesis technology.

Results: Multiple Ga-68- and Lu-177-labeled radiopharmaceuticals have now been produced and tested in vitro and in vivo, using appropriate preclinical models of prostate and breast cancer. Routine data collection for validation of radiopharmaceutical reproducibility is ongoing.

Conclusion: This presentation outlines the resources necessary and validates the steps required to establish a translational radiopharmaceutical research and production facility for the in-house preparation of novel oncology-directed biomarkers and targeted therapeutics.

Purpose: The purpose of this study was to assess the implementation and functionality of a pharmacy medication therapy management (MTM) consult service for the treatment of anemia secondary to myelodysplastic syndrome (MDS).

Methods: This was a prospective, quality improvement project conducted from April 2015 through June 2015 at the VA Nebraska-Western Iowa Healthcare System. A pharmacy MTM consult service was developed and implemented in collaboration with hematology/oncology physicians to grant current providers the option of continuing to manage the treatment of anemia secondary to MDS for their respective patients or to transition care to pharmacy services. Treatment guidelines were developed based on current literature and followed by pharmacy services to ensure that the use of erythropoietin-stimulating agents, oral and IV iron supplementation, and/or granulocyte-colony stimulating factors were managed appropriately.

Results: Of the 3 consults entered for enrollment into the pharmacy MTM consultation service, 2 were approved and 1 was denied. All 3 consults were reviewed for enrollment by the oncology pharmacist within 24 hours or the initial order. Additionally, of the 2 patients who were approved into the consultation service, both initial visits were scheduled and conducted by pharmacy services within 24 hours of the consult being ordered.

Conclusion: Despite the limited number of patients enrolled, pharmacy was able to successfully develop and implement a pharmacy MTM consult service for the treatment of anemia secondary to MDS

Purpose: The purpose of this study was to assess the implementation and functionality of a pharmacy medication therapy management (MTM) consult service for the treatment of anemia secondary to myelodysplastic syndrome (MDS).

Methods: This was a prospective, quality improvement project conducted from April 2015 through June 2015 at the VA Nebraska-Western Iowa Healthcare System. A pharmacy MTM consult service was developed and implemented in collaboration with hematology/oncology physicians to grant current providers the option of continuing to manage the treatment of anemia secondary to MDS for their respective patients or to transition care to pharmacy services. Treatment guidelines were developed based on current literature and followed by pharmacy services to ensure that the use of erythropoietin-stimulating agents, oral and IV iron supplementation, and/or granulocyte-colony stimulating factors were managed appropriately.

Results: Of the 3 consults entered for enrollment into the pharmacy MTM consultation service, 2 were approved and 1 was denied. All 3 consults were reviewed for enrollment by the oncology pharmacist within 24 hours or the initial order. Additionally, of the 2 patients who were approved into the consultation service, both initial visits were scheduled and conducted by pharmacy services within 24 hours of the consult being ordered.

Conclusion: Despite the limited number of patients enrolled, pharmacy was able to successfully develop and implement a pharmacy MTM consult service for the treatment of anemia secondary to MDS

Purpose: The purpose of this study was to assess the implementation and functionality of a pharmacy medication therapy management (MTM) consult service for the treatment of anemia secondary to myelodysplastic syndrome (MDS).

Methods: This was a prospective, quality improvement project conducted from April 2015 through June 2015 at the VA Nebraska-Western Iowa Healthcare System. A pharmacy MTM consult service was developed and implemented in collaboration with hematology/oncology physicians to grant current providers the option of continuing to manage the treatment of anemia secondary to MDS for their respective patients or to transition care to pharmacy services. Treatment guidelines were developed based on current literature and followed by pharmacy services to ensure that the use of erythropoietin-stimulating agents, oral and IV iron supplementation, and/or granulocyte-colony stimulating factors were managed appropriately.

Results: Of the 3 consults entered for enrollment into the pharmacy MTM consultation service, 2 were approved and 1 was denied. All 3 consults were reviewed for enrollment by the oncology pharmacist within 24 hours or the initial order. Additionally, of the 2 patients who were approved into the consultation service, both initial visits were scheduled and conducted by pharmacy services within 24 hours of the consult being ordered.

Conclusion: Despite the limited number of patients enrolled, pharmacy was able to successfully develop and implement a pharmacy MTM consult service for the treatment of anemia secondary to MDS

Background: Many people with advanced noncurable malignancies have unrealistic expectations of palliative cancer treatment, including the belief that treatment may cure their cancer. However, qualitative data describing how patients define cure or other treatment goals are lacking. We initiated a pilot study to assess patient understanding of the goals of palliative anticancer treatment.

Methods: Patients with advanced noncurable malignancy were eligible. Enrolled patients completed a structured interview with both quantitative and qualitative components to assess their understanding of treatment goals and their perceptions of clinical interactions. Additional data included age, race/ethnicity, education, type of malignancy, comorbidities, and palliative care involvement.

Results: We enrolled 30 patients initiating noncurative anticancer treatment. Ages ranged from 58 to 92 years. The most common malignancies were lung (33%) and prostate (17%) cancers. Ninety-three percent reported that their doctors explained things in “a way you can understand” and provided “as much information as you want” about treatment. However, only 53% accurately reported that treatment was “not at all likely” to cure their cancer; 40% reported some chance of cure; and 7% weren’t sure. Patient-reported definitions of cure ranged from “make it go away” to “no further symptoms” to “less pain.” Of those who reported some chance of cure, about half defined cure as eradication, but half used more traditionally palliative language. Overall, 80% reported that treatment was “very” or “somewhat” likely to help them live longer, and their definitions of “live longer” ranged from “wake up the next morning” to “20 more years” to “live to 105.”

Conclusions: Patient-reported definitions of “cure” and other reatment goals vary widely, and a substantial number of patients reported unrealistic expectations. These results suggest the need for an intervention to improve patient-physician communication to ensure that patients fully understand the goals of their palliative treatments.

Background: Many people with advanced noncurable malignancies have unrealistic expectations of palliative cancer treatment, including the belief that treatment may cure their cancer. However, qualitative data describing how patients define cure or other treatment goals are lacking. We initiated a pilot study to assess patient understanding of the goals of palliative anticancer treatment.

Methods: Patients with advanced noncurable malignancy were eligible. Enrolled patients completed a structured interview with both quantitative and qualitative components to assess their understanding of treatment goals and their perceptions of clinical interactions. Additional data included age, race/ethnicity, education, type of malignancy, comorbidities, and palliative care involvement.

Results: We enrolled 30 patients initiating noncurative anticancer treatment. Ages ranged from 58 to 92 years. The most common malignancies were lung (33%) and prostate (17%) cancers. Ninety-three percent reported that their doctors explained things in “a way you can understand” and provided “as much information as you want” about treatment. However, only 53% accurately reported that treatment was “not at all likely” to cure their cancer; 40% reported some chance of cure; and 7% weren’t sure. Patient-reported definitions of cure ranged from “make it go away” to “no further symptoms” to “less pain.” Of those who reported some chance of cure, about half defined cure as eradication, but half used more traditionally palliative language. Overall, 80% reported that treatment was “very” or “somewhat” likely to help them live longer, and their definitions of “live longer” ranged from “wake up the next morning” to “20 more years” to “live to 105.”

Conclusions: Patient-reported definitions of “cure” and other reatment goals vary widely, and a substantial number of patients reported unrealistic expectations. These results suggest the need for an intervention to improve patient-physician communication to ensure that patients fully understand the goals of their palliative treatments.

Background: Many people with advanced noncurable malignancies have unrealistic expectations of palliative cancer treatment, including the belief that treatment may cure their cancer. However, qualitative data describing how patients define cure or other treatment goals are lacking. We initiated a pilot study to assess patient understanding of the goals of palliative anticancer treatment.

Methods: Patients with advanced noncurable malignancy were eligible. Enrolled patients completed a structured interview with both quantitative and qualitative components to assess their understanding of treatment goals and their perceptions of clinical interactions. Additional data included age, race/ethnicity, education, type of malignancy, comorbidities, and palliative care involvement.

Results: We enrolled 30 patients initiating noncurative anticancer treatment. Ages ranged from 58 to 92 years. The most common malignancies were lung (33%) and prostate (17%) cancers. Ninety-three percent reported that their doctors explained things in “a way you can understand” and provided “as much information as you want” about treatment. However, only 53% accurately reported that treatment was “not at all likely” to cure their cancer; 40% reported some chance of cure; and 7% weren’t sure. Patient-reported definitions of cure ranged from “make it go away” to “no further symptoms” to “less pain.” Of those who reported some chance of cure, about half defined cure as eradication, but half used more traditionally palliative language. Overall, 80% reported that treatment was “very” or “somewhat” likely to help them live longer, and their definitions of “live longer” ranged from “wake up the next morning” to “20 more years” to “live to 105.”

Conclusions: Patient-reported definitions of “cure” and other reatment goals vary widely, and a substantial number of patients reported unrealistic expectations. These results suggest the need for an intervention to improve patient-physician communication to ensure that patients fully understand the goals of their palliative treatments.

Purpose: The New Mexico Veterans Affairs Health Care System (NMVAHCS) is striving to improve personalized cancer care and prevention through early identification of hereditary cancer syndromes. Detection of genetic syndromes remains vital for the implementation of precise therapeutic options and prevention measures offering improved veteran-centered care.

Background: Numerous genomic discoveries have provided personalized therapeutic options for improving clinical management of hereditary disease. However, the NMVAHCS lacks professionally trained genetic counselors to appropriately assess and address genetic testing. Primary care physicians lack specialized knowledge regarding appropriate use, application of genetic architectures, and an understanding of result interpretation. This lack of knowledge leaves providers reluctant to apply genomics in clinical practice or utilize testing on inappropriate patients, which remains costly and increases risk for litigation.

Methods: Increasing NMVAHCS access to appropriate genetic counseling involved initiating telehealth consults through the Veteran Affairs Genomic Medicine Service (VAGMS) in Salt Lake, Utah. After seeking stakeholder input and addressing availability of telehealth equipment, VAGMS was contacted. Telehealth service agreements, memorandum of understanding, and information security was obtained to allow offsite access into veterans’ charts. Clinics and consults were built into the computerized patient record system (CPRS), and staff training occurred to learn the intricacies of coordinating virtual appointments and awareness of available service. Initially, consults were limited for breast cancer risk evaluation (BRCA1 and BRCA2 mutations), to establish process flow, before opening all genetic counseling consults.

Results: Five appropriately identified veterans received breast cancer risk consults within the first week with fee-based cost savings of over $25,000. Counseling empowered veterans and families with information providing personalized therapeutic options and improving satisfaction and overall outcomes. Although the cost of breast-conserving surgery vs mastectomy remains relatively equal, prophylactic therapies reduce overall associated costs and the psychosocial distress of treating breast cancer, which is estimated to be well over $100,000.

Implications: Increasing access to genetic counseling and testing through partnering with a proven VA genetic program provides veterans with personalized, proactive therapeutic options. The role of genetics will continue to evolve and require collaboration to insure optimal application of precision care for prevention and management of veterans and family members at risk for disease.

Purpose: The New Mexico Veterans Affairs Health Care System (NMVAHCS) is striving to improve personalized cancer care and prevention through early identification of hereditary cancer syndromes. Detection of genetic syndromes remains vital for the implementation of precise therapeutic options and prevention measures offering improved veteran-centered care.

Background: Numerous genomic discoveries have provided personalized therapeutic options for improving clinical management of hereditary disease. However, the NMVAHCS lacks professionally trained genetic counselors to appropriately assess and address genetic testing. Primary care physicians lack specialized knowledge regarding appropriate use, application of genetic architectures, and an understanding of result interpretation. This lack of knowledge leaves providers reluctant to apply genomics in clinical practice or utilize testing on inappropriate patients, which remains costly and increases risk for litigation.

Methods: Increasing NMVAHCS access to appropriate genetic counseling involved initiating telehealth consults through the Veteran Affairs Genomic Medicine Service (VAGMS) in Salt Lake, Utah. After seeking stakeholder input and addressing availability of telehealth equipment, VAGMS was contacted. Telehealth service agreements, memorandum of understanding, and information security was obtained to allow offsite access into veterans’ charts. Clinics and consults were built into the computerized patient record system (CPRS), and staff training occurred to learn the intricacies of coordinating virtual appointments and awareness of available service. Initially, consults were limited for breast cancer risk evaluation (BRCA1 and BRCA2 mutations), to establish process flow, before opening all genetic counseling consults.

Results: Five appropriately identified veterans received breast cancer risk consults within the first week with fee-based cost savings of over $25,000. Counseling empowered veterans and families with information providing personalized therapeutic options and improving satisfaction and overall outcomes. Although the cost of breast-conserving surgery vs mastectomy remains relatively equal, prophylactic therapies reduce overall associated costs and the psychosocial distress of treating breast cancer, which is estimated to be well over $100,000.

Implications: Increasing access to genetic counseling and testing through partnering with a proven VA genetic program provides veterans with personalized, proactive therapeutic options. The role of genetics will continue to evolve and require collaboration to insure optimal application of precision care for prevention and management of veterans and family members at risk for disease.

Purpose: The New Mexico Veterans Affairs Health Care System (NMVAHCS) is striving to improve personalized cancer care and prevention through early identification of hereditary cancer syndromes. Detection of genetic syndromes remains vital for the implementation of precise therapeutic options and prevention measures offering improved veteran-centered care.

Background: Numerous genomic discoveries have provided personalized therapeutic options for improving clinical management of hereditary disease. However, the NMVAHCS lacks professionally trained genetic counselors to appropriately assess and address genetic testing. Primary care physicians lack specialized knowledge regarding appropriate use, application of genetic architectures, and an understanding of result interpretation. This lack of knowledge leaves providers reluctant to apply genomics in clinical practice or utilize testing on inappropriate patients, which remains costly and increases risk for litigation.

Methods: Increasing NMVAHCS access to appropriate genetic counseling involved initiating telehealth consults through the Veteran Affairs Genomic Medicine Service (VAGMS) in Salt Lake, Utah. After seeking stakeholder input and addressing availability of telehealth equipment, VAGMS was contacted. Telehealth service agreements, memorandum of understanding, and information security was obtained to allow offsite access into veterans’ charts. Clinics and consults were built into the computerized patient record system (CPRS), and staff training occurred to learn the intricacies of coordinating virtual appointments and awareness of available service. Initially, consults were limited for breast cancer risk evaluation (BRCA1 and BRCA2 mutations), to establish process flow, before opening all genetic counseling consults.

Results: Five appropriately identified veterans received breast cancer risk consults within the first week with fee-based cost savings of over $25,000. Counseling empowered veterans and families with information providing personalized therapeutic options and improving satisfaction and overall outcomes. Although the cost of breast-conserving surgery vs mastectomy remains relatively equal, prophylactic therapies reduce overall associated costs and the psychosocial distress of treating breast cancer, which is estimated to be well over $100,000.

Implications: Increasing access to genetic counseling and testing through partnering with a proven VA genetic program provides veterans with personalized, proactive therapeutic options. The role of genetics will continue to evolve and require collaboration to insure optimal application of precision care for prevention and management of veterans and family members at risk for disease.