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| # Department of Veterans Affairs  | # VHA DIRECTIVE 2003-034          |
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| **Veterans Health                 |                                   |
| Administration**                  |                                   |
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| **Washington, DC 20420**          | **June 20, 2003**                 |
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**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.]{.underline}** 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]{.underline}.** 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.]{.underline}** 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.]{.underline}** 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.]{.underline}** 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.]{.underline}** 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]{.underline}**

\(1\) 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]{.underline}**

\(1\) 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 [Physicians Data Query
(PDQ](http://www.cancer.gov/cancerinfo/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 [National Library of
Medicine](http://www.cancer.gov/cancerinfo/pdq/) 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.]{.underline}** 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.]{.underline}**

\(1\) 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]{.underline}**

\(1\) 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]{.underline}**

\(1\) 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.]{.underline}**
Cancers of the nasopharynx, larynx, lung (except mesothelioma) and
squamous cell carcinoma of the skin.

b\. **[Full body Exposure to Nitrogen Mustard.]{.underline}** 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]{.underline} - chronic lymphocytic
leukemia.