Can Veterans in Rural Areas Facing Lung Cancer Access Experts Via Telemedicine?
Can Veterans in Rural Areas Facing Lung Cancer Access Experts Via Telemedicine? from Patient Empowerment Network on Vimeo.
Are there telemedicine options for veterans living in rural areas? Expert Dr. Michael Kelley from Duke University School of Medicine discusses the rural residence rate of veterans, consultation services, and second opinions.
[ACT]IVATION TIP
“And you can actually get a second opinion where you have a video visit with the expert as well. So these things are all available. So patients can ask for these for a second opinion. And there’s somebody else in the VA who would be an expert that we would connect the patient with.”
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Transcript:
Lisa Hatfield:
I live in a more rural area of the country, if you have a patient who lives in a more rural area or maybe goes to a smaller VA facility for healthcare and they’re diagnosed with non-small cell lung cancer, can they access maybe through telemedicine visits, somebody who is more specialized in that type of cancer within the VA system, or how is that handled for veterans?
Dr. Michael Kelley:
Yes. So about a third of enrolled veterans live in rural areas. So this is very common for us. That’s 33 percent and the nation is about 14 percent. So it’s about two-and-a-half times likely that a veteran will be in a rural area. So VA has very mature advanced telehealth capabilities. We have tele ICU. We have tele emergency room services. And we have teleoncology. So there’s a national teleoncology service. It basically provides an expert in your cancer type at your VA. And this is mostly serving rural veterans.
I think the last number I saw was 44 percent of the veterans that are served by the national teleoncology service are in rural areas. So I practice in South Dakota and Arkansas, and I live in North Carolina. And I do only lung cancer. So this is a service that I think my colleagues also participate in around the country. And we’re able to get the expertise to the patient rather than the patient coming to the expertise.
Lisa Hatfield::
That’s very helpful for patients. I know I have a different type of cancer, a blood cancer, but being able to access at least the expertise of a specialist makes a big difference in my care. And, of course, my local oncologists are great, but they’re willing to work with my specialists. So I appreciate that the VA has such a brilliant advanced system for that. That’s a really impressive statistic that many patients, veterans use that telehealth option.
Dr. Michael Kelley:
Yeah, so in addition to the direct care, we also provide consultation services. So you mentioned that your local provider is willing to work with an expert. So we do that as well. So we can have what are called e-consults, electronic consults, where the local oncologist who might be a generalist is able to ask a question to an expert.
And because we are such a large system, we have an expert in everything. And I literally mean everything. So we have an expert lined up to be able to respond to every question and from any disease that is in the realm of oncology or hematology.
Lisa Hatfield:
Okay. And will that typically happen during a visit, or is it up to the patient to request that e-consult if they would like one?
Dr. Michael Kelley:
So it’s typically up to the provider, if they think they need a second opinion or they need help interpreting this, interpreting an opinion. But the patient can always ask as, you know, that you can ask their provider, talk to their provider, which I understand from a patient’s perspective can be sort of a sensitive issue is, “Hey, I don’t trust you. You’re my doctor, but I don’t trust you. Can you ask someone else for an opinion?” But you can do it in a way which is very respectful, obviously, and it’s totally okay with us, that, I’m always happy to ask a colleague to look at a case if a patient asks.
And you can actually get a second opinion where you have a video visit with the expert as well. So these things are all available. So patients can ask for these for a second opinion. And there’s somebody else in the VA who would be an expert that we would connect the patient with.
Lisa Hatfield:
Thank you for reassuring patients that it’s okay to do that. I know sometimes we’re afraid of offending our providers, but as you said, it’s okay to politely say, “This is very scary for me. I would like to know if there’s any way to do an e-consult with another physician. So yeah, thank you for reassuring patients that that’s okay to do that.
Dr. Michael Kelley:
Yeah. There should be nothing that any patient ever asks or brings up with us that is offensive to us. Your concern is our concern. So don’t be afraid to ask for it. My biggest concern is that you won’t let me know when you have a concern.
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Do Disparities Exist for Black and Latinx Veterans Facing Lung Cancer?
Do Disparities Exist for Black and Latinx Veterans Facing Lung Cancer? from Patient Empowerment Network on Vimeo.
Do Black and Latinx veterans face lung cancer disparities? Expert Dr. Michael Kelley from Duke University School of Medicine discusses past and current health outcome disparities and comparisons of molecular genetic alterations between Black and white veterans.
[ACT]IVATION TIP
“…if you are experiencing a challenge in working with the VA healthcare system, regardless of what community you are in, please communicate that to someone at the VA. That could be your provider, that could be the patient advocate. Every VA hospital has a patient advocate or that could be someone else at the medical center. We want to know how we can help you in what problems you’re experiencing.”
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Related Resources:
Equitable Access: Overcoming Challenges in Precision Medicine for Veterans with Lung Cancer |
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Navigating Lung Cancer Clinical Trials: VA Support and Resources for Veterans |
Transcript:
Lisa Hatfield:
Dr. Kelley, what specific challenges do veterans from the Black and Latinx communities face when trying to access lung cancer healthcare services?
Dr. Michael Kelley:
So in VA, there are several different ethnic and racial populations, and we’ve looked at the outcomes of Black and white veterans. Latinx veteran population is still relatively small, so we don’t have good statistical power to be able to draw strong conclusions there. But the comparison between Black and white is very clear in VA in lung cancer in terms of the outcomes.
And the result is, is that Black veterans do just as well, or better than white veterans at every stage of lung cancer. That is quite different than it is in the rest of the country. So that is one area that I think VA as an integrated healthcare system with wraparound services is able to brag about that we are able to provide all the care that is necessary to derive that outcome.
That wasn’t always the case. In the early 2000s, there was a difference in surgery rates for Black veterans with early stage lung cancer. And we were studying this, and what we saw was that, that difference went away about 2009 or 2010, and it hasn’t come back since we last looked at it. We don’t know what caused it, and we don’t know why it went away, but we’re glad to see it did go away. There are a long list of other possible challenges that veterans in Black or Latinx communities might face. These may be overlapping with those that everyone faces, but VA probably has a service to help with it.
And so my activation tip for you is, is that if you are experiencing a challenge in working with the VA healthcare system, regardless of what community you are in, please communicate that to someone at the VA. That could be your provider, that could be the patient advocate. Every VA hospital has a patient advocate or that could be someone else at the medical center. We want to know how we can help you in what problems you’re experiencing.
Lisa Hatfield:
Are there any differences in the characteristics of the cancer for these populations for the Black and Latinx communities that you have seen?
Dr. Michael Kelley:
We have looked at a lot of comparisons between Black and white groups of veterans, not so much around Latinx because of the smaller numbers. There are not a lot of differences in terms of molecular genetic alterations. And so there are some differences in the geography. So the Black African Americans veterans tend to live more in the Southeast, where actually there’s the largest collection of military veterans who are enrolled in VA care anyways.
But in terms of the outcomes, we don’t really see any outcomes. There are some other differences in medical care that are appropriate, such as a variation of normal in terms of the white blood cell count that happens in some individuals predominantly in of African descent. And those individuals might be at risk for having their chemotherapy doses reduced, because their white count goes down more than other individuals. But in general, we don’t see a lot of differences between those populations medically.
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Equitable Access: Overcoming Challenges in Precision Medicine for Veterans with Lung Cancer
Equitable Access: Overcoming Challenges in Precision Medicine for Veterans with Lung Cancer from Patient Empowerment Network on Vimeo.
Do veterans with lung cancer face barriers to precision medicine and targeted therapies? Expert Dr. Michael Kelley from Duke University School of Medicine discusses past and current access to precision medicine, the National Precision Oncology Program, and proactive patient advice to ensure you receive essential testing and optimal care.
[ACT]IVATION TIP
“…if you have advanced lung cancer, ask your provider, what testing has been done on my tumor, what are the results, and what does that mean for my treatment?”
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Related Resources:
Do Disparities Exist for Black and Latinx Veterans Facing Lung Cancer? |
|
Navigating Lung Cancer Clinical Trials: VA Support and Resources for Veterans |
Transcript:
Lisa Hatfield:
Dr. Kelley, what specific challenges do veterans face in accessing precision medicine? And how can these challenges be mitigated to ensure equitable access to advanced treatments?
Dr. Michael Kelley:
So before 2016, the first cancer moonshot, there were major challenges in, not only in the VA, but across the country to access to precision medicine in the oncology field. We launched in that year, and if really now provide access to cutting-edge precision oncology technology, which is a lot of molecular testing and the expertise to be able to interpret the results of that test to apply it to individual patients. So I think we have advanced to the point where this should not be a barrier anywhere in the VA system, but I would say that only about half of veterans are enrolled for VA care.
And outside of VA there still are areas that have a variety of different barriers to getting the testing done on the tumor samples in a way which informs the treatment decision-making for patients. So this is very important. My activation tip for this is to be sure to ask your provider whether your tumor has been tested for molecular tests, and if so, what the results of those tests are, and how that impacts the treatment of your cancer.
Lisa Hatfield:
Dr. Kelley, can you speak to your research around barriers to prescribing targeted therapies for patients with non-small cell lung cancer with highly actionable gene variants, and what should patients and their care partners be aware of related to these barriers?
Dr. Michael Kelley:
So one of the key pieces of information that your providers need to know in order to, how to treat your advanced stage lung cancer is what are the molecular alterations in your tumor, and what types of proteins are expressed on the surface of the proteins that allows them to make good choices around immune therapy and another group of therapies called targeted therapies, and that can make major differences in your care and your outcome.
So when we first started using this type of testing, in particular the genetic testing of tumor samples, there was a lot of complexity in the results that was not well understood by the oncology providers, because it was new and very complex. So VA has instituted a program to provide that testing and the expert consultation service to be able to interpret those results.
And so when we set up that program, which is called the National Precision Oncology Program, we did a study, looking to see how many patients who should have gotten a targeted drug actually got that drug. And the results were similar to what has been reported in other healthcare systems. And that is, is that less than every patient was getting the targeted therapy, and it was about somewhere around a third of patients who did not get the therapy that would’ve been indicated by that test result.
So we wanted to know what the reasons were, and I think we’ve addressed a lot of the reasons that we came upon. A lot of it is education and making sure that the information from those tests gets to the provider and gets to the patient, and that comes with an understanding of what those test results mean. So my activation tip is, if you have advanced lung cancer, ask your provider, what testing has been done on my tumor, what are the results, and what does that mean for my treatment?
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Do Veterans Face Health Disparities in Lung Cancer Care?
Do Veterans Face Health Disparities in Lung Cancer Care? from Patient Empowerment Network on Vimeo.
Are there any lung cancer disparities that veterans face? Expert Dr. Michael Kelley from Duke University School of Medicine discusses smoking rates of veterans, the quality of VA care versus the general population, potential environmental exposures during military service, and proactive advice for optimal lung cancer care.
[ACT]IVATION TIP
“… if you have cancer, then you should be taken care of in a way which addresses your needs regardless of what the availability is within the VA system. VA sometimes cannot take care of all patients with cancer, and in that case, VA will purchase a service in the community.”
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Lisa Hatfied:
Dr. Kelley, can you discuss any disparities or differences in health outcomes among veterans compared to the general population when it comes to access to treatment? And are there systemic issues within the healthcare system that disproportionately affect veterans?
Dr. Michael Kelley:
So there are some differences between what types of cancers that veterans get and the general population, but there is not a bright line difference between those two groups. They’re really gradations, and if you have the same type of cancer and you’re in the VA versus outside the VA, the treatment approaches and prognosis should be the same.
And that’s actually what we see when you look at systematic studies of the quality of care of inside the VA compared to the rest of the country. The VA care, it looks the same or better almost routinely, and that is, I think, due to the uniform availability of services that are not only the medical care, but some wraparound services that are available to veterans.
There are some differences that we want to talk about. One is related to smoking. So military veterans have a higher rate of previous smoking. The current smoking rate is about the same as the general population, so it’s more likely that they will get smoking-related malignancies, and, of course, lung cancer is one of those cancers.
Military veterans also have exposures during their service to a lot of other physical, chemical, and other types of exposures, which can increase their risk of a variety of different types of cancers. And those can also show up in different subpopulations within the services depending on where they served. But many studies that explored some types of associations that were thought to be existent turned out not to show a difference.
So, for example, breast cancer and active duty military women is actually lower than it is in the general population. So there are some differences, but they go both ways. So I don’t want to make any general statements. But my activation tip is that, if you have cancer, then you should be taken care of in a way which addresses your needs regardless of what the availability is within the VA system. VA sometimes cannot take care of all patients with cancer, and in that case, VA will purchase a service in the community.
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Are There Lung Cancer Outcome Disparities for Veterans?
Are There Lung Cancer Outcome Disparities for Veterans? from Patient Empowerment Network on Vimeo.
Do lung cancer outcome disparities exist for veterans? Expert Dr. Drew Moghanaki from UCLA Health discusses veteran outcome studies for civilian versus VA healthcare, efforts on improving outcomes over time, and proactive advice for accessing the best lung cancer care.
[ACT]IVATION TIP
“…if you’ve got cancer, to really understand lung cancer, to really appreciate that there’s been a lot of advances and if you’re not feeling that you have access to those advances, get a second opinion and go to a bigger place that actually has an integrated approach to lung cancer care with a multidisciplinary team with the doctors in different specialties are working together and are focused on giving the best lung cancer care.”
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Transcript:
Lisa Hatfield:
Dr. Moghanaki, can you discuss any disparities or differences in health outcomes among veterans compared to the general population when it comes to lung cancer treatment?
Dr. Drew Moghanaki:
Yeah, when it comes to lung cancer treatment, there’s new data that’s showing that since the discovery of better drugs and safer surgery and more effective radiotherapy, that survival rates are improving gradually, especially over the last 10 years. We’ve seen this same trend with VA data as well, that veterans, whether they’re getting care in a community or in the VA, the outcomes are getting better.
Are there disparities? Well, there’s notable disparities that we’ve identified which is that although outcomes in general are getting better for female and male and Black and white and other ethnic sections of the population, there continues to be a disparity in the civilian sector in that our Black patients, whether civilian or veteran, have inferior outcomes. And, of course, we know this is associated largely with other socioeconomic issues related to a long history of racism in this country that’s led to segregation and unequal access to health care and well-being opportunities.
But what we see in the VA, whether you’re Black or white, actually the outcomes are the same. So there’s something that VA is doing that’s addressing the barriers that are affecting people in the general population. And in fact, we see in some of our studies, Black veterans actually have better outcomes. And so we’re learning that it’s much more than just biology by itself, that there really are socioeconomic factors. And when you’ve got a healthcare system that’s more than just a healthcare system, it’s a benefit system as well.
We really provide a nice safety net that helps address those disparities. But the sad truth is that it definitely disparities do continue to exist outside the VA healthcare system. So my activation tip is, if you’re a veteran with maybe some less resources than others, again, check into the VA because the VA provides not just healthcare, but also a lot of support services, especially when you have lung cancer, which as mentioned, is just very difficult to deliver and requires more than just access to a doctor.
Lisa Hatfield:
And I’d like to mention a paper also that you published regarding improving outcomes over a certain time period. There was a paragraph in there where you had a discussion about potential contributing factors to the improvement of outcomes over time. Are you willing to discuss those a little bit, what those potential factors are for improving outcomes in patients with lung cancer?
Dr. Drew Moghanaki:
Yeah, there are three main components. One is making sure you get the diagnosis right. Making sure you do the right biopsies and you send the specimens for what’s called biomarker testing to make sure you know what type of lung cancer. There’s now more than a dozen different types of lung cancer. And if you don’t get that biomarker test, you’re not going to know. You’re just going to be treated with standard therapy. If you get the biomarker testing, you can get personalized medicine with a drug that’s more likely to work and probably safer than the older conventional chemotherapies, which still has a role. But sometimes we can skip chemotherapy altogether and go directly to a targeted therapy.
The second big advancement comes in the treatment delivery itself. So surgical treatments are now much less invasive than ever before. In fact, many of our patients, they go to the operating room, they wake up with four Band-Aids, and half their lung is removed. Remarkable technology using robotic and video-assisted technologies. Same with radiotherapy.
Patients lay on a table and the machine, the very sophisticated machine just rotates around them, zaps these tumors. The patient can actually drive themselves back and forth to treatment and go home and and live their lives. We’ve got patients getting lung radiotherapy, and they’re playing golf the next day. It’s unbelievable. And then the third really comes down to survivorship, which is that our patients, even if we really can’t cure their cancer, like a lot of advanced diabetes, we just can’t cure, we can keep our patients going as they live a high-quality life moving forward and make sure that their journey, unfortunately, with their lung cancer that they obviously didn’t ever want to have, that their journey is the best that it can be.
So my activation tip here is if you’ve got cancer, to really understand lung cancer, to really appreciate that there’s been a lot of advances and if you’re not feeling that you have access to those advances, get a second opinion and go to a bigger place that actually has an integrated approach to lung cancer care with a multidisciplinary team were the doctors in different specialties are working together and are focused on giving the best lung cancer care.
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Combating Disparities: Veterans’ Healthcare Access and Quality
Combating Disparities: Veterans’ Healthcare Access and Quality from Patient Empowerment Network on Vimeo.
Where can veterans locate quality healthcare and healthcare access? Expert Dr. Drew Moghanaki from UCLA Health shares information from VA healthcare research studies and proactive advice for patients to access the best care.
[ACT]IVATION TIP
“…make sure that the quality of care isn’t inferior, check in with the VA and see how they might be able to help you, especially if you’ve got lung cancer, because lung cancer care is complicated.”
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Veteran Lung Cancer Risk | Understanding Exposures and Screening Protocols |
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Advancements in Lung Cancer Clinical Trials Updates for Veterans |
Transcript:
Lisa Hatfield:
Dr. Moghanaki, are there disparities in the quality of care received by veterans compared with other patient populations? And can you speak to the strategies or programs that have been effective in addressing barriers to healthcare access for veterans?
Dr. Drew Moghanaki:
I love this question because it is one of the most informative things that I’ve learned since becoming a VA physician. Study after study has shown that the quality of care received by veterans is equal or superior to that received in the community. And that’s largely in the VA healthcare system. So again, if you’ve got access to VA healthcare, I think you might be eligible, please look into it. The reports have been fantastic, and that’s because it’s a comprehensive approach to care. But for veterans who are receiving care in the community, it’s a little bit harder, actually it’s a lot harder to track. Because they may not be registered with the VA. And what’s happening, I saw the VA is happening outside the VA.
And I think that largely speaking veterans are just going to get the same kind of level of care as their neighbors might who are civilian. And so where they’re going for their care really affects that. Now, veterans may have more resources, because they can tap into the VA to find out where they may go. VA has incredible tracking systems, a lot of data to help us make better decisions and for them to make better decisions. And so my activation tip here is to make sure that the quality of care isn’t inferior, check in with the VA and see how they might be able to help you, especially if you’ve got lung cancer, because lung cancer care is complicated.
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Do Black and Latinx Veterans Face Unique Lung Cancer Challenges?
Do Black and Latinx Veterans Face Unique Lung Cancer Challenges? from Patient Empowerment Network on Vimeo.
What unique challenges do Black and Latinx veterans face in lung cancer? Expert Dr. Drew Moghanaki from UCLA Health explains the importance of trust, second opinions, and proactive advice for the best care.
[ACT]IVATION TIP
“…for anyone who might have some trust concerns. No one owns you as a provider that you have to get care from them. If you’re comfortable, you can ask for a second opinion. If not, it is absolutely okay. Patients all the time are getting second and sometimes even third opinions. And I strongly recommend getting another opinion if you’ve got any questions or doubts, because that trust alliance is so important to get the best lung cancer care…”
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Transcript:
Lisa Hatfield:
Dr. Moghanaki, what specific challenges do veterans from the Black and Latinx communities face when trying to access healthcare services, and what are we learning from these challenges, and how is that information shaping care for veterans facing lung cancer?
Dr. Drew Moghanaki:
Well, this question just reminds me that healthcare is complicated, especially lung cancer care. And the most important thing for anybody getting care, regardless of what social, economic background or ethnic background they may be from, is to find a team that you trust and who you know will care about you. And that’s the best way to make sure you get the best treatment. I myself as a physician. I’ve also been a patient at times. And if I don’t trust my care provider, I basically ask for a change. And I know that can be difficult.
And so here’s my activation tip for anyone who might have some trust concerns. No one owns you as a provider that you have to get care from them. If you’re comfortable, you can ask for a second opinion. If not, it is absolutely okay. Patients all the time are getting second and sometimes even third opinions. And I strongly recommend getting another opinion if you’ve got any questions or doubt, because that trust alliance is so important to get the best lung cancer care, because it’s not going to be a one-time visit. You were talking about relationships that can last months or even years to get the best treatment for your lung cancer.
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