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December 2021 News |
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Wishing you and yours a happy, peaceful, and healthy holiday season |
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From the Editor Russell Crawford, BPharm, BCOP (Ret.)
Life kinda feels like the movie “Groundhog Day” these days, the more things change the more they really don’t. COVID appears to be declining, and then it isn’t. Vaccines offer hope for a decrease in disease and disease-related symptoms, yet fully vaccinated individuals still get sick with COVID. The debate over “mandatory” vaccinations is never ending, understanding each individuals point of view regarding this topic is critical but doesn’t solve the debate.
So, we “keep on keeping on” with the priority remaining the patients that we serve while the CDC, FDA and politicians try to come to a common resolve that best serves society. Until then, we continue to be both our own and our patients best advocate to live as healthy and normal a life that is possible during these times.
I hope the holiday season serves as a bit of a “distraction” for you all, so that we remember what in life is important to us, and how to preserve that. I hope you are able to reunite with your families and loved ones this year, and make up for lost time from the past 24 months. I hope that you remain healthy and COVID free, and that your family, co-workers and patients do as well. The holidays are a time to reflect on the positive aspects of life and love and faith, not a time to dwell on the current state of affairs that it appears we have very little control over beyond using common sense. No matter your faith or religion, I wish you all the happiest and safest of Holiday seasons and hopefully 2022 will not continue to feel like Groundhog Day. |
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From AVAHO Administration Julie Lawson, Executive Director
As Sue and I close out 2021, we are excited at what 2022 will bring AVAHO and its members. Technology is booming - especially in the remote learning arena - and we are busy searching for and testing new platforms to bring more CE-eligible training and networking options to you. Look for more frequent online opportunities in 2022, as well as improved digital options at the 2022 Annual Meeting!
This year's Annual Meeting in Denver (September 24-26) was a wonderful chance to see so many of our members in-person again. Nearly 400 individuals joined us in person and more than 200 online, creating a great network of learning and engagement.
I also encourage you to join us online January 20, 2022 for our Business Meeting. We'll provide programmatic, committee, financial and business updates and provide information on coming opportunities. The meeting should take approximately 30 minutes, and if you're available afterwards we encourage you to network online with your peers!
And finally, Sue and I, along with our Board of Directors, wish you the best of holiday seasons. We hope you are able to get some rest, spend time with loved ones, and remain healthy for 2022!
We look forward to working with you in the new year,
Julie Lawson and Sue Lentz
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WELCOME 2021-22 BOARD MEMBERS!
The results of the recent AVAHO board elections are in, and we're pleased to announce your 2021-22 Board of Directors:
President: Bernadette Heron, PharmD, BCOP President-Elect: Janice Schwartz, MSN, RN, OCN Secretary: Jane Looney, BS MT, MA, MS Treasurer: Brian Dahl, PharmD, BCOP
Members: Tony Quang, MD, JD, Immediate Past President Cindy Bowman, MSN, RN, OCN Rusty Crawford, B Pharm, BCOP (Ret.) Dwight Eplin, PharmD, BCOP Mark Klein, MD Angela Schoppet, CTR
Thank you to all who voted and congratulations to all nominated. |
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INTERNAL WISDOM Articles of interest and information from AVAHO members |
My breast cancer journey from the “other” side of the chair Kourtney LaPlant, AVAHO Member and Education Committee member
Part 2: Meeting the treatment team and getting the chemo train rolling
The medical world moves either very quickly or very slowly around the holidays. Luckily, I was able to get a surgical consult entered fairly quickly. I had asked around to see which surgeon came highly recommended. The response was overwhelmingly leading to one surgeon in particular, so I was pleased that I was able to get in to be seen before everyone left for holiday vacations.
Consult day came and my husband and I nervously waited for the surgeon to enter the room. This consult was going to drive every piece going forward, so we had waited for this day for what felt like months. As Tom Petty says, “the waiting is the hardest part”.
The surgeon walked in and went over my biopsy results. I had a list of questions about stage, what sort of therapy, etc. She wanted more imaging, a genetics panel, appointments with medical oncology and radiation oncology, and to get me set up with physical therapy. You could tell that she had this conversation with MANY patients before myself and seemed to anticipate the questions I already had. She did her best to lay out a plan, took her time with explaining the details and answer our questions. By the end of the appointment, we had a plan for neoadjuvant chemotherapy then surgery.
The steps after surgery would be determined after the final path came back. Radiation was a possibility, but that would depend on a number of factors to be determined at a later date.
That afternoon, I received a call from my oncologist (see, things can move quickly…). She recommended that I enroll in the CompassHER2 trial. The goal of the trial is to see if paclitaxel, trastuzumab and pertuzumab work in reducing the need for further chemotherapy after surgery in patients with HER2+ breast cancer. The hope was for a pathologic complete response at the time of surgery, but we needed to get the therapy underway. This sounded like a plan to me. It was less chemo than I was expecting (hooray!) but the thought of paclitaxel did scare me a bit. I had seen my fair share of infusion reactions in the clinic and I just had this feeling in the back of my mind that things were about to get interesting.
The time period between Christmas and the New Year was a flurry of appointments. I had blood drawn for genetics, a breast MRI, met with physical therapy (who basically told me I was out of shape and needed to lose weight…duh), had an echo, and met with medical oncology and the research team to sign consents and enroll in the trial. My case was discussed in the multidisciplinary tumor board and we were all set to go. I was waiting on insurance authorization, but had a tentative chemo start date of January 7th. We decided to wait on placing a port since I didn’t necessarily need one. We were all on the same page and had a plan. A plan is good, but all of this was happening while trying to make sure Santa came to visit, spending a week with my in laws and trying to keep my family from completely losing their minds with my diagnosis.
Chemo day
January 7th came pretty quickly. I had a lovely PT session at 7AM that morning to get my heart pumping and get my arm measurements in case I had issues with lymphedema after surgery. Afterward, I walked upstairs and checked in for infusion. I was called back and I settled into my chemo chair, I knew that it was going to be a long infusion day since I needed loading doses of both trastuzumab and pertuzumab. My nurse was very sweet and got an IV started with one stick. I do have decent veins, but every time I moved my arm I set off the pump alarm. That was just plain annoying!
The infusion room was cold and the chairs were a lovely shade of tan plastic. There was enough room in each little alcove for my chair and the infusion pump. There were no TVs, no fancy tablets or video players and not a lot of room for any visitors. This place was HUGE. They had 46 chairs total, much larger than I was used to working in. I was in the “research corner”. Patients on clinical trial get to sit in this sectioned off area for infusions, why I’m not quite sure. My husband was given a very uncomfortable plastic chair to sit in and I had a couple of warm blankets and a pillow to try and make the situation bearable. We had some friends that worked at the hospital stop by to say hey and wish me well. I guess word got back to the infusion room pharmacist because my IV bags came out with festive stickers on them. It was definitely the highlight of my day.
I got through the premeds, didn’t nap (even with a full dose of benadryl) and was getting ready for the paclitaxel. I had told my husband I didn’t really care what else happened as long as I didn’t have an infusion reaction. I apparently spoke too soon!
My nurse had seen her fair share of taxol reactions as well. She started the pump and stayed by my chair. We all just kind of sat there staring at each other and making small talk. All of a sudden I felt my stomach start churning and I felt very hot. I turned bright red and my nurse immediately stopped the infusion. Then everyone came running, which is not uncommon when one of these occur.
The charge nurse started asking questions to my nurse about what premeds I had received and how long into the infusion I was when the excitement started happening. I didn’t let the nurse answer, and I started answering the questions myself. Apparently I felt the need to be in charge of the situation. They were trying to decide what rescue medications to give and I had an opinion on that as well. All the while my husband is trying to tell me to be quiet, but I just couldn’t help myself.
Things calmed down and it was time to make a decision whether to restart the infusion or call it quits for the day. My oncologist gave the go ahead to restart but at half the rate-which meant another two hours in the chair. Needless to say, it was a long day by the time everything was done and I was ready to go home and chill. Luckily, I didn’t have any issues with nausea, just felt like I had been physically put through the ringer.
I wasn’t prepared for what the next day would bring. I went to work with the intention of lasting a full day. We have a weekly video huddle with our work team. The joy of video meetings during a pandemic is that everyone can see what you look like, good or bad. I made it until lunch time before my boss convinced me to take the rest of the day off. She took one look at me at this meeting and told me to take some leave. My face was very flushed and my brain was foggy, my guess is lovely leftovers from the day before. I gave in and spent the rest of the day on the couch. That’s when the tears started. I had a couple of friends stop by to check on me and bring me some sweet treats (not helping my PT situation), but I couldn’t really say much to them at the door without my eyes welling up with tears. Up until now, I didn’t feel like a cancer patient. That all changed once these “chemotions” hit. All of the adrenaline of a diagnosis, waiting on plans and them finally getting started just caught up with me, all at once.
The kids had been staying with my parents for a couple of days while we figured out how I was going to tolerate therapy. I missed them but was sort of relieved that I only had to take care of myself for the time being. I felt like a wimp. I hated feeling like I needed to be taken care of but knew that I needed some help. I was worn out and still on an emotional roller coaster. This was only after one dose, is this what it was going to be like for the next 11 weeks?
More from your colleagues:
Glutamine Supplementation for Common Side Effects of Chemo and
CML Diagnosis 101: The Importance of Assigning the Correct Diagnostic Code Maria Ribeiro, MD; James Duvel, PharmD; Samantha McClelland, PharmD; Donna Leslie, PharmD; Mark Geraci, PharmD, BCOP; Bernadette Heron, PharmD, BCOP; for the VHA PBM Anti-Cancer Stewardship
TAKE CARE OF YOUR L.E.G.S
Prepared by: Tracy Chen, PharmD; Ereca Nguyen, PharmD; Soo Park, MD
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The Impact of HCC on Veterans and the VA Healthcare System
A video featuring AVAHO members, brought to you in collaboration with MDedege and Federal Practitioner
In this video, the panelists discuss risk factors for HCC and why they are seeing increasing rates of the disease among the veteran population. They also review the barriers facing the veteran community that could affect screening rates and treatment. |
VA Articles of Interest
Prostate Cancer Prostatic Dis. 2020 Jun;23(2):252-259. doi: 10.1038/s41391-019-0178-6. Epub 2019 Oct 17.
Tobacco smoking and death from prostate cancer in US veterans Paul Riviere 1 2, Abhishek Kumar 1 2, Elaine Luterstein 1, Lucas K Vitzthum 1 2, Vinit Nalawade 1 2, Reith R Sarkar 1 2, Alex K Bryant 1 2, John P Einck 1, Arno J Mundt 1, James D Murphy 1 2, Brent S Rose 3 4
Affiliations 1Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA. 2VA San Diego Health Care System, La Jolla, CA, USA.
Background: Cigarette smoking is a risk factor for mortality in several genitourinary cancers, likely due to accumulation of carcinogens in urine. However, in prostate cancer (PC) the link has been less studied. We evaluated differences in prostate cancer-specific mortality (PCSM) between current smokers, past smokers, and never smokers diagnosed with PC.
Methods: This was a retrospective cohort study of PCSM in men diagnosed with PC between 2000 and 2015 treated in the US Veterans Affairs health care system, using competing risk regression analyses.
Results: The cohort included 73,668 men (current smokers: 22,608 (30.7%), past smokers: 23,695 (32.1%), and never smokers: 27,365 (37.1%)). Median follow-up was 5.9 years. Current smoker patients were younger at presentation (median age current: 63, never: 66; p < 0.001), and had more advanced disease stage (stage IV disease current: 5.3%, never: 4.3%; p < 0.04). The 10-year incidence of PCSM was 5.2%, 4.8%, and 4.5% for current, past, and never smokers, respectively. On competing risk regression, current smoking was associated with increased PCSM (subdistribution hazard ratio: 1.14, 95% confidence interval: (1.05-1.24), p = 0.002), whereas past smoking was not. Hierarchical regression suggests that this increased risk was partially attributable to tumor characteristics.
Conclusions: Smoking at the time of diagnosis is associated with a higher risk of dying from PC as well as other causes of death. In contrast, past smoking was not associated with PCSM suggesting that smoking may be a modifiable risk factor. PC diagnosis may be an important opportunity to discuss smoking cessation.
Clin J Oncol Nurs. 2020 Jun 1;24(3):331-334. doi: 10.1188/20.CJON.331-334. Veterans With Cancer: Providing Care in the Community Mary Laudon Thomas
Affiliation VA Palo Alto Health Care System.
Cancer is more prevalent in the military veteran population than in the general population and is often associated with radiation and chemical exposures encountered while in service. Veterans with cancer may have complex comorbidities, including mental health conditions and social challenges, that can interfere with successful cancer treatment. As more veterans receive their cancer care in the community outside the Veterans Health Administration (VHA), oncology nurses must be aware of these issues and provide appropriate interventions to increase the likelihood that positive cancer treatment outcomes are realized for these patients.
Psychooncology. 2021 Apr;30(4):581-590. doi: 10.1002/pon.5605. Epub 2020 Dec 13. Posttraumatic stress disorder and suicide among veterans with prostate cancer Maya Aboumrad 1, Brian Shiner 1 2, Lorelei Mucci 3, Nabin Neupane 1, Florian R Schroeck 1 2, Zachary Klaassen 4, Stephen J Freedland 5 6, Yinong Young-Xu 1 2
Affiliations 1White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.
Objective: To evaluate the effect of a preexisting posttraumatic stress disorder (PTSD) diagnosis on suicide and non-suicide mortalities among men with newly diagnosed prostate cancer, and examine potential mediating factors for the relationship between PTSD and suicide.
Methods: We used patient-level data from Veterans Health Administration electronic medical records to identify men (age ≥40 years) diagnosed with prostate cancer between 2004 and 2014. We used Fine and Gray regression model to estimate the risk for competing mortality outcomes (suicide, non-suicide, and alive). We used structural equation models to evaluate the mediating factors.
Results: Our cohort comprised 214,649 men with prostate cancer, of whom 12,208 (5.7%) had a preexisting PTSD diagnosis. Patients with PTSD compared to those without utilized more healthcare services and had lower risk cancer at diagnosis. Additionally, they experienced more suicide deaths (N = 26, 0.21% vs. N = 269, 0.13%) and fewer non-suicide deaths (N = 1399, 11.5% vs. N = 45,625, 22.5%). On multivariable analysis, PTSD was an independent suicide risk factor (HR = 2.35; 95% CI: 1.16, 4.78). Depression, substance use disorder, and any definitive prostate cancer treatment were partial mediators. However, PTSD was associated with lower non-suicide mortality risk (HR = 0.86; 95% CI: 0.77, 0.96).
Conclusion: Patients with PTSD experienced greater suicide risk even after adjusting for important mediators. They may have experienced lower non-suicide mortality risk due to favorable physical health resulting from greater healthcare service use and early diagnosis of lower risk cancer. Our findings highlight the importance of considering psychiatric illnesses when treating patients with prostate cancer and the need for interventions to ameliorate suicide risk.
Mil Med. 2020 Mar 2;185(3-4):512-518. doi: 10.1093/milmed/usz291. Breast Cancer Risk Assessment and Chemoprevention Use Among Veterans Affairs Primary Care Providers: A National Online Survey Balmatee Bidassie 1, Amanda Kovach 1, Marissa A Vallette 1, Joseph Merriman 2 3, Yeun-Hee Anna Park 4 5, Anita Aggarwal 6, Sarah Colonna 3 Affiliations 1Clinical Partnerships in Healthcare Transformation (CPHT), VA-Center for Applied Systems Engineering (VA-CASE), Veterans Engineering Resource Center (VERC), 2669 Cold Springs Road, Building 9, Indianapolis, IN 46222.
Introduction: Breast cancer is the most common cancer diagnosed among women and the second most common cause of cancer death among women. There are ways to reduce a woman's risk of breast cancer; however, most eligible women in the United States are neither offered personalized screening nor chemoprevention. Surveys have found that primary care providers are largely unaware of breast cancer risk assessment models or chemoprevention. This survey aims to investigate Veterans Health Administration primary care providers' comfort level, practice patterns, and knowledge of breast cancer risk assessment and chemoprevention. Materials and methods: An online, Research Electronic Data Capture-generated survey was distributed to VHA providers in internal medicine, family medicine, and obstetrics/gynecology. Survey domains were provider demographics, women's health experience, comfort level, practice patterns, barriers to using risk models and chemoprevention, and knowledge of chemoprevention.
Results: Of the 167 respondents, 33.1% used the Gail model monthly or more often and only 2.4% prescribed chemoprevention in the past 2 years. Most VHA primary care providers did not answer chemoprevention knowledge questions correctly. Designated women's health providers were more comfortable with risk assessment (P < 0.018) and chemoprevention (P < 0.011) and used both breast cancer risk models (P < 0.0045) and chemoprevention more often (P < 0.153). Reported barriers to chemoprevention were lack of education and provider time. Conclusions: VHA providers and women Veterans would benefit from a system to ensure that women at increased risk of breast cancer are identified with risk modeling and that risk reduction options, such as chemoprevention, are offered when appropriate. VHA providers requested risk reduction education, which could improve primary care provider comfort level with chemoprevention.
J Womens Health (Larchmt). 2019 Feb;28(2):268-275. doi: 10.1089/jwh.2018.6936. Epub 2018 Jun 19. Cancer Among Women Treated in the Veterans Affairs Healthcare System Leah L Zullig 1 2, Karen M Goldstein 1 3, Kellie J Sims 4, Christina D Williams 4 5, Michael Chang 6, Dawn Provenzale 4 7, Michael J Kelley 5 8 9 10
Affiliations 11 Center for Health Services Research in Primary Care , Durham Veterans Affairs Health Care System, Durham, North Carolina. Abstract Background: The Veterans Affairs (VA) healthcare system is a high-volume provider of cancer care. Women are the fastest growing patient population using VA healthcare services. Quantifying the types of cancers diagnosed among women in the VA is a critical step toward identifying needed healthcare resources for women Veterans with cancer.
Materials and methods: We obtained data from the VA Central Cancer Registry for cancers newly diagnosed in calendar year 2010. Our analysis was limited to women diagnosed with invasive cancers (e.g., stages I-IV) between January 1, 2010, and December 31, 2010, in the VA healthcare system. We evaluated frequency distributions of incident cancer diagnoses by primary anatomical site, race, and geographic region. For commonly occurring cancers, we reported distribution by stage.
Results: We identified 1,330 women diagnosed with invasive cancer in the VA healthcare system in 2010. The most commonly diagnosed cancer among women Veterans was breast (30%), followed by cancers of the respiratory (16%), gastrointestinal (12%), and gynecological systems (12%). The most commonly diagnosed cancers were similar for white and minority women, except white women were significantly more likely to be diagnosed with respiratory cancers (p < 0.01) and minority women were significantly more likely to be diagnosed with gastrointestinal cancers (p = 0.03). Conclusions: Understanding cancer incidence among women Veterans is important for healthcare resource planning. While cancer incidence among women using the VA healthcare system is similar to U.S civilian women, the geographic dispersion and small incidence relative to male cancers raise challenges for high quality, well-coordinated cancer care within the VA.
Semin Oncol. Aug-Oct 2019;46(4-5):321-326. doi: 10.1053/j.seminoncol.2019.10.001. Epub 2019 Oct 24. Utilization of the Veterans Affairs Central Cancer Registry to evaluate lung cancer outcomes Mark Klein 1, George Scaria 2, Apar Kishor Ganti 3
Affiliations 1Hematology/Oncology Section, Primary Care Service Line, Minneapolis VA Health Care System, Minneapolis, Minnesota; Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota. Electronic address: mark.klein2@va.gov. Abstract Lung cancer is one of the most common and difficult to treat cancers. Veterans are disproportionately affected by lung cancer, as approximately 20% of all cancers diagnosed within the Veteran Affairs health system are lung cancers. Many Veterans have extensive comorbidities, and thus they are often excluded from clinical trials based on this and other eligibility criteria. Thus, while clinical trials are the gold standard to guide treatment decisions, many Veterans' clinical situations will not align with clinical trial criteria. The Department of Veterans Affairs has established a Central Cancer Registry to aid in evaluation of cancer outcomes and other studies, and data in the registry date back to 1995. This has provided a rich source of data for outcome-based and other research. Here, we highlight studies that utilized the Veterans Affairs Central Cancer Registry to analyze lung cancer outcomes in Veterans treated within the Veterans Affairs health system.
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