Document Details
VHA Dir 2003-034, NATIONAL CANCER STRATEGY
- Click : 0
- Download : 0
- File Size : 19.32 K
- Document Type :
Memo
:
VHA Dir 2003-034, NATIONAL CANCER STRATEGY
VHA DIRECTIVE 2003-034
June 20, 2003
VHA DIRECTIVE
2003-034
June 20, 2003
VHA DIRECTIVE 2003-034
June 20, 2003
VHA DIRECTIVE
2003-034
June 20, 2003
VHA DIRECTIVE
2003-034
June 20, 2003
Department
of Veterans Affairs
VHA
DIRECTIVE 2003-034
Veterans
Health Administration
Washington,
DC 20420
June 20, 2003
NATIONAL
CANCER STRATEGY
1. PURPOSE:
This Veterans Health Administration (VHA) Directive provides the structure
for VHA's National Cancer Strategy.
2. BACKGROUND
a.
Cancer is a varied and complex collection of diseases having many causes
and clinical characteristics. According to the American Cancer
Society, it will claim more than 556,500 American lives in 2003, including
a substantial fraction of the Department of Veterans Affairs (VA's)
estimated 175,000 veteran cancer patients. Cancer imposes a severe and
in some ways unique burden of illness. Morbidity and mortality
from the disease itself are significant, and one's quality of life
may be dramatically reduced by currently available treatment.
Arguably, it is the most feared of diseases, and its diagnosis imposes
a significant emotional burden on both patients and their families.
Approximately 35,000 new cases of cancer occur in VA patients each year;
and cancer is the second leading cause of death among veterans.
Moreover, the course of the disease is often protracted, and the treatment
is quite demanding of resources. As the veteran population ages,
this encumbrance will increase. It is necessary that VA formalize
its approach to this group of diseases. The purpose of this national
VA cancer strategy is to ensure that users of the veterans health care
system have easy access to consistently high-quality cancer prevention,
detection and treatment services.
NOTE:
See Attachment B for malignancies recognized as presumed service
connected.
b.
Objectives. The specific objectives of this strategy
are to:
(1)
Ensure that the quality of VA cancer care meets or exceeds accepted
national standards of practice;
(2)
Improve cancer patients' access to care;
(3)
Provide appropriate cancer management expertise to each patient as promptly
as possible;
(4)
Provide for the continual monitoring and improvement of the outcomes
of therapy;
(5)
Provide clinically useful prevention, screening and early detection
services;
(6)
Improve the quality of life of cancer patients;
(7)
Provide compassionate and humane care that clearly demonstrates respect
for the patients' dignity;
(8)
Ensure that the care provided derives from shared decision making between
the patient and treatment personnel;
THIS VHA
DIRECTIVE EXPIRES ON JUNE 30, 2008
(9)
Ensure that through its clinical research activities VA continually
builds upon current knowledge, contributes to the national research
base, and provides for state-of-the-art preventive, diagnostic and therapeutic
interventions;
(10)
Facilitate patient access to promising interventions;
(11)
Contribute to the common good by establishing a national model for a
systematic approach to the problem of cancer; and
(12)
Ensure that suitable and timely patient-centered end-of-life care is
made available, when appropriate.
c.
Strategy Elements. This strategy addresses:
(1)
Prevention and education,
(2)
Screening,
(3)
Early detection and diagnosis,
(4)
Treatment,
(5)
Rehabilitation,
(6)
Clinical investigation and research,
(7)
Tumor registry, and
(8)
Continuing and end of life care.
3. POLICY:
It is VHA policy that all Veterans Integrated Service Networks (VISNs)
and medical center Directors implement, as appropriate, the National
Cancer Strategy.
4. ACTION
a.
Chief Patient Care Officer. The Chief Patient Care Officer
(11) is responsible for ensuring that:
(1)
This strategy is reviewed and revised as appropriate by the responsible
office at least every 5 years, or more often as necessitated by changing
circumstances. NOTE: See Attachment A for
elements of the National Cancer Strategy.
(2)
Increased VA participation in clinical trials is accomplished in accordance
with the Interagency Agreement (IAA) of January 1, 2000, between VA
and the National Cancer Institute (NCI), and all VISN Directors, facility
Directors, Clinical Managers, and Chiefs of Staff are familiar with
that document.
b.
VISN Directors. VISN Directors are responsible for
ensuring that:
(1)
In designated Comprehensive Cancer Centers, rehabilitation services
are made available for both inpatients and outpatients.
(2)
VA facilities pursue group membership in the NCI cooperative group program,
or the Community Clinical Oncology Program (CCOP), or its affiliate
memberships.
c.
Medical Center Director.
Each medical center Director is responsible for ensuring that:
(1)
A tumor registry is established, and the data provided is reported the
Central Cancer Registry is a timely manner.
(2)
A formal relationship with organizations providing hospice care is established
ensuring that hospice services are available to every appropriate VA
cancer patient when the need so arises.
(3)
If the facility provides or participates in palliative care, there is
a formal, evidence-based protocol for pain management, and that documentation
of adequate pain relief is recorded in the patient's medical record.
(4)
If clinical research in oncology is being conducted at the facility,
primacy consideration to NCI-sponsored and VA Cooperative Group research
studies must be given consideration over more limited local or regional
protocols.
5. REFERENCES
a.
Interagency Agreement (IAA) of January 1, 2000, between VA and NCI.
b.
1997 VHA-NCI IIA.
c.
Physicians Data Query (PDQ) Database, NCI, available through the National
Library of Medicine.
6. FOLLOW-UP RESPONSIBLITY:
Patient Care Services (11) is responsible for the contents of this Directive.
Questions may be directed to 202-273-8490.
7. RESCISSION:
None. This VHA Directive expires on June 30, 2008.
S/ Louise Van
Diepen for
Robert H. Roswell, M.D.
Under Secretary for Health
Attachments
DISTRIBUTION:
CO:
E-mailed 6/27/2003
FLD:
VISN, MA, DO, OC, OCRO, and
200 - E-mailed 6/27/2003
ATTACHMENT A
ELEMENTS
OF THE NATIONAL CANCER STRATEGY
1. Prevention.
Prevention and education are central to a comprehensive approach to
the management of any neoplastic disease. All medical facilities
must provide and promote programs to encourage lifestyle changes such
as smoking cessation and dietary counseling, as well as evidence-based
disease prevention services which include, but are not limited to, those
contained in the United States (U.S.) Preventive Services Task Force
Guide and those recommended by the Department of veterans Affairs (VA)
National Center for Disease Prevention and Health Promotion.
2. Screening
(1)
Many screening issues are controversial, and objective data does not
always support some opinions about the value of implementation of a
number of screening practices. The value of any cancer screening
practice is demonstrated by the extent to which it has been confirmed
to reduce morbidity and mortality. Prolongation of survival is
insufficient evidence to support screening, since earlier diagnosis
results in longer survival whether or not early treatment, or any treatment,
is effective.
(2)
VA shall utilize screening practices, which have been shown to be evidence-based.
Those endorsed by the U.S. Preventive Services Task Force are considered
appropriate for standardization in VA. Recommendations by other
groups or professional associations such as the American College of
Physicians, the American Cancer Society, et al., needs to be carefully
considered by clinicians; utilization of those recommendations should
be based upon the physician's best judgment combined with the wishes
of the individual patient subsequent to careful counseling by treatment
personnel about the risks and benefits of screening.
3. Clinical
Practice Recommendations
(1)
VA recognizes the utility of evidence-based standards in providing best
practices to our patients, as well as the complexity and difficulty
inherent in developing them. Recommendations can only be as valid
and reliable as the evidence upon which they are based. Moreover,
they require frequent review and revision as new information becomes
available. In addition, appropriate recommendations must be promulgated
and disseminated widely and in a timely fashion, and be easily accessible
to clinicians. For all of those reasons, the recommendations contained
in the <a href=http://www.cancer.gov/cancerinfo/pdq/Physicians
Data Query (PDQ)
database provided by the National Cancer Institute (NCI) and made available
through the National Library of Medicine represent the standard of care
to be provided in VA, and are designated as the VA national cancer care
guideline.
(2)
PDQ recommendations are the result of a comprehensive review by national
cancer experts, and are based upon objective data carefully evaluated
according to the strength of evidence. These statements are reviewed
by the respective editorial boards at frequent intervals, thus assuring
contemporaneous information. The database is electronically available
through the <a href=http://www.cancer.gov/cancerinfo/pdq/National
Library of Medicine
24 hours a day, at every VA medical facility. As part of the 1997
VHA-NCI Interagency Agreement, the NCI has agreed to provide PDQ for
any VA facility or clinic lacking such access. NOTE:
The Under Secretary for Health strongly encourages that cancer patients
be provided the "patient version" PDQ related to their disease
so as to improve joint decision making.
4. Rehabilitation.
Rehabilitation is an integral component of cancer care. In designated
Comprehensive Cancer Centers, rehabilitation services must be made available
for both inpatients and outpatients. This treatment must be provided
through the use of physical, occupational, recreational, and speech
therapy services, at a minimum. Every facility caring for cancer
patients has an obligation to provide rehabilitation directly or by
appropriate referral.
5. Clinical
Investigation and Research.
(1)
Clinical trials provide an avenue for VA to make available to veteran
patients new preventive, diagnostic, or treatment options, which may
become the standard of future care. Further, they represent the only
reliable process to acquire objective data suitable for the provision
of efficacious and cost-effective patient care. Increased VA participation
in clinical trials will be accomplished in accordance with the Interagency
Agreement (IAA) of January 1, 2000, between VA and NCI, and all Veterans
Integrated Service Networks (VISN) and facility directors and clinical
managers and chiefs of staff are expected to be familiar with that document.
(2)
The basic intent of this new partnership is to increase the access of
eligible veterans to NCI-sponsored trials of new preventive, diagnostic,
and treatment interventions, and to provide VA clinical investigators
with expanded opportunities to participate in clinical research.
VA facilities are to pursue group membership in the NCI cooperative
group program, or the Community Clinical Oncology Program (CCOP) or
its affiliate memberships. VA facilities conducting clinical research
in oncology must give primacy consideration to NCI-sponsored and VA
Cooperative Group research studies over more limited local or regional
protocols. In addition, particular attention needs to be paid
to the enrollment of patients of ethnic or racial backgrounds, which
predispose to the incidence of cancer or to poorer outcomes (e.g., prostate
cancer in Afro-Americans).
6. Tumor
Registry
(1)
A formal means of tracking patient care and outcomes is a critical element
in any cancer program. This function is normally achieved through
a cancer registry.
(2)
Registries provide important epidemiological, staging, demographic,
survival, and other clinical data. A VA national tumor registry
is established; this facilitates compilation of accurate incidence statistics,
comparison of system wide outcomes with national standards, analysis
of specific therapies and outcomes, evaluation of prevention practices,
and planning for resource allocation. It also assists in providing
analytic reports and contributes to nationwide cancer information.
Each medical treatment facility must establish a tumor registry reporting
to the central registry, or provide data that may be so reported.
7. Continuing
Care and Terminal Care
(1)
The professional and ethical obligations of VA providers does not end
when it is clear that further therapeutic interventions do not hold
the hope of cure. Indeed, it is then that the greater challenges
to medical care begin. It is not appropriate to believe, and never
to state, that there is no more that can be done for the patient.
While cure may not be possible, care is always needed to provide a dignified
and comfortable end to life which should be as free as possible from
anxiety, pain, and suffering.
(2)
VA is actively engaged in the national effort to develop precepts, guidelines,
and research-based outcome measures for palliative care. The Under
Secretary for Health endorses the "Elements of Quality Care for
Patients in the Last Phase of Life" established by the Institute
for Ethics at the American Medical Association. VA also supports
the recommendations of the Institute of Medicine on Care at the End
of Life. The National Hospice Organization has published "A
Pathway for Patients and Families Facing Terminal Illness" that
is organized around the outcome areas of self-determination, safe, and
comfortable dying, and effective grieving. VA clinicians are strongly
encouraged to use this systematic approach to care of terminally ill
patients and their families.
(3)
Every VA medical treatment facility shall provide or have a formal relationship
with organizations providing hospice care; those relationships must
ensure that hospice services are made available to every appropriate
VA cancer patient when the need so arises. Pain management is
of critical importance in these circumstances, and current evidence
demonstrates that pain relief is virtually always possible, though frequently
not achieved. VA facilities providing or participating in palliative
care must have a formal, evidence-based protocol for pain management.
Documentation of adequate pain relief in the patient's medical record
is essential.
(4)
The foundation of continuing and terminal care needs to afford dignity,
comfort, communication, and the company of loved ones during a patient's
final days. This is provided through services, which reduce discomfort
while attending to the unique clinical, ethical, and spiritual care
that is needed.
ATTACHMENT B
MALIGNANCIES
RECOGNIZED BY VA AS PRESUMED TO BE SERVICE CONNECTED BASED ON HAZARDOUS
EXPOSURES
1. EXPOSURE TO MUSTARD
GAS NOTE: Must be full-body exposures.
a.
Full-body Exposure to Nitrogen or Sulfur Mustard. Cancers
of the nasopharynx, larynx, lung (except mesothelioma) and squamous
cell carcinoma of the skin.
b.
Full body Exposure to Nitrogen Mustard. Acute nonlymphocytic
leukemia.
2. EXPOSURE TO IONIZING
RADIATION. NOTE: Limited to atmospheric
nuclear weapons test participants, occupation forces in Hiroshima and
Nagasaki, plus others listed in Title 38 Code of Federal Regulations
(CFR) 3.309(d) (3) (ii) (C) and (D). All forms of leukemia
except chronic lymphocytic leukemia, cancer of the thyroid, bone, brain,
breast, colon, lung, ovary, pharynx, esophagus, stomach, small intestine,
pancreas, bile ducts, gall bladder, salivary gland, urinary tract (kidneys,
renal pelvis, ureter, urinary bladder and urethra), lymphomas (except
Hodgkin's disease), multiple myeloma, primary liver cancer, and bronchioloalveolar
carcinoma (a rare lung cancer).
3. EXPOSURE TO CERTAIN
HERBICIDE AGENTS. NOTE: Service in
Vietnam establishes exposure; exposure to herbicides in other locations
must be confirmed by official records. Non-Hodgkin's lymphoma,
soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's
sarcoma, or mesothelioma), Hodgkin's disease, multiple myeloma, respiratory
cancers (lung, larynx, trachea and bronchus), prostate cancer; in
process of being added - chronic lymphocytic leukemia.
A-
A-
B-
VHA Dir 2003-034, NATIONAL CANCER STRATEGY
VHA DIRECTIVE 2003-034
June 20, 2003
VHA DIRECTIVE
2003-034
June 20, 2003
VHA DIRECTIVE 2003-034
June 20, 2003
VHA DIRECTIVE
2003-034
June 20, 2003
VHA DIRECTIVE
2003-034
June 20, 2003
Department
of Veterans Affairs
VHA
DIRECTIVE 2003-034
Veterans
Health Administration
Washington,
DC 20420
June 20, 2003
NATIONAL
CANCER STRATEGY
1. PURPOSE:
This Veterans Health Administration (VHA) Directive provides the structure
for VHA's National Cancer Strategy.
2. BACKGROUND
a.
Cancer is a varied and complex collection of diseases having many causes
and clinical characteristics. According to the American Cancer
Society, it will claim more than 556,500 American lives in 2003, including
a substantial fraction of the Department of Veterans Affairs (VA's)
estimated 175,000 veteran cancer patients. Cancer imposes a severe and
in some ways unique burden of illness. Morbidity and mortality
from the disease itself are significant, and one's quality of life
may be dramatically reduced by currently available treatment.
Arguably, it is the most feared of diseases, and its diagnosis imposes
a significant emotional burden on both patients and their families.
Approximately 35,000 new cases of cancer occur in VA patients each year;
and cancer is the second leading cause of death among veterans.
Moreover, the course of the disease is often protracted, and the treatment
is quite demanding of resources. As the veteran population ages,
this encumbrance will increase. It is necessary that VA formalize
its approach to this group of diseases. The purpose of this national
VA cancer strategy is to ensure that users of the veterans health care
system have easy access to consistently high-quality cancer prevention,
detection and treatment services.
NOTE:
See Attachment B for malignancies recognized as presumed service
connected.
b.
Objectives. The specific objectives of this strategy
are to:
(1)
Ensure that the quality of VA cancer care meets or exceeds accepted
national standards of practice;
(2)
Improve cancer patients' access to care;
(3)
Provide appropriate cancer management expertise to each patient as promptly
as possible;
(4)
Provide for the continual monitoring and improvement of the outcomes
of therapy;
(5)
Provide clinically useful prevention, screening and early detection
services;
(6)
Improve the quality of life of cancer patients;
(7)
Provide compassionate and humane care that clearly demonstrates respect
for the patients' dignity;
(8)
Ensure that the care provided derives from shared decision making between
the patient and treatment personnel;
THIS VHA
DIRECTIVE EXPIRES ON JUNE 30, 2008
(9)
Ensure that through its clinical research activities VA continually
builds upon current knowledge, contributes to the national research
base, and provides for state-of-the-art preventive, diagnostic and therapeutic
interventions;
(10)
Facilitate patient access to promising interventions;
(11)
Contribute to the common good by establishing a national model for a
systematic approach to the problem of cancer; and
(12)
Ensure that suitable and timely patient-centered end-of-life care is
made available, when appropriate.
c.
Strategy Elements. This strategy addresses:
(1)
Prevention and education,
(2)
Screening,
(3)
Early detection and diagnosis,
(4)
Treatment,
(5)
Rehabilitation,
(6)
Clinical investigation and research,
(7)
Tumor registry, and
(8)
Continuing and end of life care.
3. POLICY:
It is VHA policy that all Veterans Integrated Service Networks (VISNs)
and medical center Directors implement, as appropriate, the National
Cancer Strategy.
4. ACTION
a.
Chief Patient Care Officer. The Chief Patient Care Officer
(11) is responsible for ensuring that:
(1)
This strategy is reviewed and revised as appropriate by the responsible
office at least every 5 years, or more often as necessitated by changing
circumstances. NOTE: See Attachment A for
elements of the National Cancer Strategy.
(2)
Increased VA participation in clinical trials is accomplished in accordance
with the Interagency Agreement (IAA) of January 1, 2000, between VA
and the National Cancer Institute (NCI), and all VISN Directors, facility
Directors, Clinical Managers, and Chiefs of Staff are familiar with
that document.
b.
VISN Directors. VISN Directors are responsible for
ensuring that:
(1)
In designated Comprehensive Cancer Centers, rehabilitation services
are made available for both inpatients and outpatients.
(2)
VA facilities pursue group membership in the NCI cooperative group program,
or the Community Clinical Oncology Program (CCOP), or its affiliate
memberships.
c.
Medical Center Director.
Each medical center Director is responsible for ensuring that:
(1)
A tumor registry is established, and the data provided is reported the
Central Cancer Registry is a timely manner.
(2)
A formal relationship with organizations providing hospice care is established
ensuring that hospice services are available to every appropriate VA
cancer patient when the need so arises.
(3)
If the facility provides or participates in palliative care, there is
a formal, evidence-based protocol for pain management, and that documentation
of adequate pain relief is recorded in the patient's medical record.
(4)
If clinical research in oncology is being conducted at the facility,
primacy consideration to NCI-sponsored and VA Cooperative Group research
studies must be given consideration over more limited local or regional
protocols.
5. REFERENCES
a.
Interagency Agreement (IAA) of January 1, 2000, between VA and NCI.
b.
1997 VHA-NCI IIA.
c.
Physicians Data Query (PDQ) Database, NCI, available through the National
Library of Medicine.
6. FOLLOW-UP RESPONSIBLITY:
Patient Care Services (11) is responsible for the contents of this Directive.
Questions may be directed to 202-273-8490.
7. RESCISSION:
None. This VHA Directive expires on June 30, 2008.
S/ Louise Van
Diepen for
Robert H. Roswell, M.D.
Under Secretary for Health
Attachments
DISTRIBUTION:
CO:
E-mailed 6/27/2003
FLD:
VISN, MA, DO, OC, OCRO, and
200 - E-mailed 6/27/2003
ATTACHMENT A
ELEMENTS
OF THE NATIONAL CANCER STRATEGY
1. Prevention.
Prevention and education are central to a comprehensive approach to
the management of any neoplastic disease. All medical facilities
must provide and promote programs to encourage lifestyle changes such
as smoking cessation and dietary counseling, as well as evidence-based
disease prevention services which include, but are not limited to, those
contained in the United States (U.S.) Preventive Services Task Force
Guide and those recommended by the Department of veterans Affairs (VA)
National Center for Disease Prevention and Health Promotion.
2. Screening
(1)
Many screening issues are controversial, and objective data does not
always support some opinions about the value of implementation of a
number of screening practices. The value of any cancer screening
practice is demonstrated by the extent to which it has been confirmed
to reduce morbidity and mortality. Prolongation of survival is
insufficient evidence to support screening, since earlier diagnosis
results in longer survival whether or not early treatment, or any treatment,
is effective.
(2)
VA shall utilize screening practices, which have been shown to be evidence-based.
Those endorsed by the U.S. Preventive Services Task Force are considered
appropriate for standardization in VA. Recommendations by other
groups or professional associations such as the American College of
Physicians, the American Cancer Society, et al., needs to be carefully
considered by clinicians; utilization of those recommendations should
be based upon the physician's best judgment combined with the wishes
of the individual patient subsequent to careful counseling by treatment
personnel about the risks and benefits of screening.
3. Clinical
Practice Recommendations
(1)
VA recognizes the utility of evidence-based standards in providing best
practices to our patients, as well as the complexity and difficulty
inherent in developing them. Recommendations can only be as valid
and reliable as the evidence upon which they are based. Moreover,
they require frequent review and revision as new information becomes
available. In addition, appropriate recommendations must be promulgated
and disseminated widely and in a timely fashion, and be easily accessible
to clinicians. For all of those reasons, the recommendations contained
in the <a href=http://www.cancer.gov/cancerinfo/pdq/Physicians
Data Query (PDQ)
database provided by the National Cancer Institute (NCI) and made available
through the National Library of Medicine represent the standard of care
to be provided in VA, and are designated as the VA national cancer care
guideline.
(2)
PDQ recommendations are the result of a comprehensive review by national
cancer experts, and are based upon objective data carefully evaluated
according to the strength of evidence. These statements are reviewed
by the respective editorial boards at frequent intervals, thus assuring
contemporaneous information. The database is electronically available
through the <a href=http://www.cancer.gov/cancerinfo/pdq/National
Library of Medicine
24 hours a day, at every VA medical facility. As part of the 1997
VHA-NCI Interagency Agreement, the NCI has agreed to provide PDQ for
any VA facility or clinic lacking such access. NOTE:
The Under Secretary for Health strongly encourages that cancer patients
be provided the "patient version" PDQ related to their disease
so as to improve joint decision making.
4. Rehabilitation.
Rehabilitation is an integral component of cancer care. In designated
Comprehensive Cancer Centers, rehabilitation services must be made available
for both inpatients and outpatients. This treatment must be provided
through the use of physical, occupational, recreational, and speech
therapy services, at a minimum. Every facility caring for cancer
patients has an obligation to provide rehabilitation directly or by
appropriate referral.
5. Clinical
Investigation and Research.
(1)
Clinical trials provide an avenue for VA to make available to veteran
patients new preventive, diagnostic, or treatment options, which may
become the standard of future care. Further, they represent the only
reliable process to acquire objective data suitable for the provision
of efficacious and cost-effective patient care. Increased VA participation
in clinical trials will be accomplished in accordance with the Interagency
Agreement (IAA) of January 1, 2000, between VA and NCI, and all Veterans
Integrated Service Networks (VISN) and facility directors and clinical
managers and chiefs of staff are expected to be familiar with that document.
(2)
The basic intent of this new partnership is to increase the access of
eligible veterans to NCI-sponsored trials of new preventive, diagnostic,
and treatment interventions, and to provide VA clinical investigators
with expanded opportunities to participate in clinical research.
VA facilities are to pursue group membership in the NCI cooperative
group program, or the Community Clinical Oncology Program (CCOP) or
its affiliate memberships. VA facilities conducting clinical research
in oncology must give primacy consideration to NCI-sponsored and VA
Cooperative Group research studies over more limited local or regional
protocols. In addition, particular attention needs to be paid
to the enrollment of patients of ethnic or racial backgrounds, which
predispose to the incidence of cancer or to poorer outcomes (e.g., prostate
cancer in Afro-Americans).
6. Tumor
Registry
(1)
A formal means of tracking patient care and outcomes is a critical element
in any cancer program. This function is normally achieved through
a cancer registry.
(2)
Registries provide important epidemiological, staging, demographic,
survival, and other clinical data. A VA national tumor registry
is established; this facilitates compilation of accurate incidence statistics,
comparison of system wide outcomes with national standards, analysis
of specific therapies and outcomes, evaluation of prevention practices,
and planning for resource allocation. It also assists in providing
analytic reports and contributes to nationwide cancer information.
Each medical treatment facility must establish a tumor registry reporting
to the central registry, or provide data that may be so reported.
7. Continuing
Care and Terminal Care
(1)
The professional and ethical obligations of VA providers does not end
when it is clear that further therapeutic interventions do not hold
the hope of cure. Indeed, it is then that the greater challenges
to medical care begin. It is not appropriate to believe, and never
to state, that there is no more that can be done for the patient.
While cure may not be possible, care is always needed to provide a dignified
and comfortable end to life which should be as free as possible from
anxiety, pain, and suffering.
(2)
VA is actively engaged in the national effort to develop precepts, guidelines,
and research-based outcome measures for palliative care. The Under
Secretary for Health endorses the "Elements of Quality Care for
Patients in the Last Phase of Life" established by the Institute
for Ethics at the American Medical Association. VA also supports
the recommendations of the Institute of Medicine on Care at the End
of Life. The National Hospice Organization has published "A
Pathway for Patients and Families Facing Terminal Illness" that
is organized around the outcome areas of self-determination, safe, and
comfortable dying, and effective grieving. VA clinicians are strongly
encouraged to use this systematic approach to care of terminally ill
patients and their families.
(3)
Every VA medical treatment facility shall provide or have a formal relationship
with organizations providing hospice care; those relationships must
ensure that hospice services are made available to every appropriate
VA cancer patient when the need so arises. Pain management is
of critical importance in these circumstances, and current evidence
demonstrates that pain relief is virtually always possible, though frequently
not achieved. VA facilities providing or participating in palliative
care must have a formal, evidence-based protocol for pain management.
Documentation of adequate pain relief in the patient's medical record
is essential.
(4)
The foundation of continuing and terminal care needs to afford dignity,
comfort, communication, and the company of loved ones during a patient's
final days. This is provided through services, which reduce discomfort
while attending to the unique clinical, ethical, and spiritual care
that is needed.
ATTACHMENT B
MALIGNANCIES
RECOGNIZED BY VA AS PRESUMED TO BE SERVICE CONNECTED BASED ON HAZARDOUS
EXPOSURES
1. EXPOSURE TO MUSTARD
GAS NOTE: Must be full-body exposures.
a.
Full-body Exposure to Nitrogen or Sulfur Mustard. Cancers
of the nasopharynx, larynx, lung (except mesothelioma) and squamous
cell carcinoma of the skin.
b.
Full body Exposure to Nitrogen Mustard. Acute nonlymphocytic
leukemia.
2. EXPOSURE TO IONIZING
RADIATION. NOTE: Limited to atmospheric
nuclear weapons test participants, occupation forces in Hiroshima and
Nagasaki, plus others listed in Title 38 Code of Federal Regulations
(CFR) 3.309(d) (3) (ii) (C) and (D). All forms of leukemia
except chronic lymphocytic leukemia, cancer of the thyroid, bone, brain,
breast, colon, lung, ovary, pharynx, esophagus, stomach, small intestine,
pancreas, bile ducts, gall bladder, salivary gland, urinary tract (kidneys,
renal pelvis, ureter, urinary bladder and urethra), lymphomas (except
Hodgkin's disease), multiple myeloma, primary liver cancer, and bronchioloalveolar
carcinoma (a rare lung cancer).
3. EXPOSURE TO CERTAIN
HERBICIDE AGENTS. NOTE: Service in
Vietnam establishes exposure; exposure to herbicides in other locations
must be confirmed by official records. Non-Hodgkin's lymphoma,
soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's
sarcoma, or mesothelioma), Hodgkin's disease, multiple myeloma, respiratory
cancers (lung, larynx, trachea and bronchus), prostate cancer; in
process of being added - chronic lymphocytic leukemia.
A-
A-
B-