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VA’s first tumor laboratory was established at the Hines VA Hospital. Since then, VA has gone on to become a lead in cancer care, establishing studies, linking cigarette smoking with cancer, and creating breakthroughs for veterans and the world.
Welcome to Standing Ready: An Inside Look at the Untold History of the VA's Medical Innovations. Join us as we elevate and highlight significant medical and scientific contributions of the nation's largest healthcare system.
Join us for interviews with VHA innovators and pioneers, exploring how VHA has changed the landscape of medicine over 75 years with topics on the history of prosthetic limbs, adaptive sports, how history has influenced VHA’s response to the COVID-19 pandemic, and more!
The Department of Veterans Affairs does not endorse or officially sanction any entities that may be discussed in this podcast, nor any media, products or services they may provide.
Shawn Spitler: Standing right,
the podcast that gives you an
inside look at the Untold
History of the VA medical
innovations with your host Katie
Dillard sensory and Shawn
Katie Delacenserie: Spitler. All
right. Hi, everybody. This is
Katie and Sean. Welcome back to
standing ready. Today we are
going to be examining VAs cancer
research, a fight that VA has
been involved in since 1930. And
the VAs first tumor research
laboratory was established at
the hinds VA Research Hospital.
When was this 1930? Oh, yeah,
yeah, radiologists, surgeons and
organ systems specialists work
together at tumor board met
daily to examine and discuss
patients and there was even an
active teaching program with
local and national conferences
in the latest cancer therapy
equipment.
Shawn Spitler: So how about how
far back does do we I mean, you
may not have the facts in front
of you, but do we know how far
back radiology studies go?
Katie Delacenserie: So the
history of radiology in medicine
dates back to 1895. When the
first one Yeah, yeah. When the
first discovered X ray was was
no kidding. Yeah.
Shawn Spitler: What do you mean
by discovered X? Ray? How did
we? Oh, look, there's an x ray
floating there. We can use that.
Katie Delacenserie: Okay.
Radiology began in 1895. When
we'll have run Gen.
Shawn Spitler: Rumpelstiltskin.
Yeah. Well,
Katie Delacenserie: when a
German researcher accidentally
discovered X rays, which is the
type of radiation that can
penetrate most solid objects,
the German physicist was
studying what happened when he
passed an electrical current
through different gases at low
pressure. I bet you rockin Rogen
is kind of like where they get
that radiation measure unit. I
don't know if you saw Chernobyl.
I did like that everyone
watched? Yes. Like when they
were talking about like, oh,
it's not bad. It's just 200.
Like, rockin or what? Yeah,
that's because sensor didn't go
up that
Shawn Spitler: high and
interesting.
Katie Delacenserie: So yeah, it
initially was sort of discovered
in 1895. And then by 1832. It's
a technology that's being used
at VA. And then by 1937, you
have the VA administrator,
General Frank Hines, who
announces that VA would be
joining the cancer fight by
establishing research centers at
six different clinics. And this
was a time when you know, after
World War One, they were
examining whether or not poison
gases had a connection to
cancer. So that really was sort
of the origins, kind of of this
research. And then quite quickly
went on to examine the role
between cigarette smoking and
cancer, a link that was proposed
very early on, but wasn't
actually discovered until a VA
physician by the name of Dr.
Oscar our back through his
research provided the definitive
link between cancer and
cigarettes. Okay.
Shawn Spitler: So that came from
the VA, definitive link is a VA
that's fast
Katie Delacenserie: related to
his research, which Len then led
to initial warnings by the
surgeon general in the 1960s. So
all of that is traced throughout
VAs history. And when you think
about it is especially with lung
cancer is something that's very
tied to veterans, you know, in
World War Two, they gave out
cigarettes like candy and, and
that's really something that you
start to see the effects of
later on. So it
Shawn Spitler: would it but do
we should we say more accurately
that today, they hand out candy,
like cigarettes?
Katie Delacenserie: Yeah. I
think that's just candy forever.
Like, no, maybe I could rephrase
that, you know, in World War
Two, cigarettes were a part of
the ration. That's it. That's
true. It really was sort of
ingrained, like, just like food
was into what they received. So
then you really start to have
these, you know, in the general
population, for sure, but
particularly in the veteran
population come to fruition,
which leads into Dr. artbox
groundbreaking research,
Shawn Spitler: I believe they
also used to give out in the
rations. I will fact check this
before I put the episode out,
but I believe they gave out
comic books, I believe so yeah,
this big thing with Captain
America as part of that whole
thing. And then they linked
comic books to cancer. And so I
had to stop.
Katie Delacenserie: I'm now back
on track. So today we are
sitting down with the current
iteration of VA groundbreaking
researchers to examine oncology
and that's Dr. Michael Kelly,
who comes to us from the Durham
VA Medical Center. All right,
let's do it. All right. So Dr.
Michael Kelly is the director of
VAs national oncology program
and professor of medicine at the
Duke University Medical School.
Dr. Kelly, thank you for joining
us on standing ready today. As
the director of VAs national
oncology program, can you You
give us an overview of the work
that you do.
Unknown: So first of all, thank
you for inviting me. Very
pleased to be here on your
podcast, I think the overview is
is that we provide care for for
veterans were diagnosed with
cancer. And we do that in a very
comprehensive fashion. I'm a
medical oncologist, which is a
type of cancer specialist, which
uses medications. So that's the
area that we focus on mostly,
but we go across the spectrum.
We don't do cancer screening. So
patients who don't yet have
cancer is not the core of what
we do we collaborate with others
that do that, but anything from
diagnosis to end of treatment.
Cancer is a multidisciplinary
area. So there are many
different specialists who may
play a role. And we help to
coordinate those areas. And then
we have a lot of work that we're
doing in precision oncology,
which is a type of personalized
medicine for patients with
cancer. We do data, so there's a
cancer registry as nationwide,
we make sure that we identify
all the patients who have cancer
so that we can understand
patterns of development of
cancer and both veterans and the
population of the nation as a
whole, and understand how to
best take care of them. So
there's a lot of different
things. And I probably left out
three or four.
Katie Delacenserie: You've
talked a little bit about
precision oncology. Can you
explain to our listeners a
little bit more about that and
how that's grown within VA?
Unknown: Yeah, so proceed, what
does precision means is this
concept of tailoring care for a
particular patient. And when we
talk about that, for oncology
patients or patients who have
cancer, that means not only the
characteristics of the patient,
so you know, sex, age, other
medical conditions, what
medications you're taking, but
other characteristics about you.
So it might be what genes you
inherited from your parents. And
more specifically, more
frequently, it means what Gene
alterations or other
characteristics, there are of
the tumor itself. Alright, so
tumors can be what's called
heterozygous, meaning that they
can be different in different
parts of it. But they have some
characteristics, which are we
think are sort of present in
most of the tumor cells, or all
the tumor cells that start very
early on in the process that
leads to cancer, these changes
occur relatively early, and
those are the types of changes
that we're looking for. So, in
essence, this the big concept
is, is how can you tailor this
for this patient and doing that
tailoring, we understand that
therapy is more likely to be
effective, it's more likely to
be specific or targeted to the
problem and not to everything
else. So you have fewer side
effects. So those are the two
characteristics that we're
looking for, from precision
medicine in general and
oncology. It means understanding
what's causing the cancer in a
particular individual, and how
does the individuals
constitution if you will
contribute to that environment.
So this is DNA, sometimes RNA,
protein, and we've looked at
protein markers for decades. So
this started in some time ago,
in terms of the oncology
practice, is in the late 1990s.
There was a drug which was
developed called mat nib or ugly
vac is one of the trade names
for it. And it was used in a
disease called Chronic
Myelogenous Leukemia, or CML.
And it was really a advance of
the sort of the dream
proportions where it, it works
really well, where the prior
treatments didn't work very
well, and it had many fewer side
effects. And so it changed this,
this condition of a disease,
which was invariably fatal to
one where you just take this
pill, and it's now a chronic
condition for most people. So
that that paradigm has been
accelerated since then. And it
really came about in terms of
more common solid tumors like
lung cancer, prostate cancer,
and colon cancer and all these
others more recently, and it was
during this period, where the
White House had an initiative
that they announced in early
2016, called the Cancer Moonshot
Initiative. And that was led by
now President Biden to bring
together many different partners
and many of them in the federal
agency. each federal agency was
requested to review what they
could contribute to advancing
the progress which was being
made, but to accelerate the rate
at which that progress is being
made for patients who have
cancer. And that is a time when
VA did that evaluation to try to
understand what we could
contribute, and to see if there
was something that that we
should be doing that we weren't
already doing. And that was part
of that was precision oncology.
So we had started this as a
regional program. And it was
serving a small number of
medical centers. And we took
that and made it a national
program very rapidly, and
started to deliver expert
services in conjunction with
this service of sequencing
patients tumors. So first, you
have to understand, you have to
get a piece of the tumor sample,
it has to go to a laboratory and
undergoes sequencing. So you can
see what variations are there,
what mutations are in the
cancer, and then you have to
interpret the result. So both of
those are challenging. There's a
lot of reasons why sequencing
tumor samples are challenging,
but interpreting it is also
extremely challenging, because
there are many different genes
involved. And the signals that
are coming from the sequencing
results are, you have to
understand it, you have to be
again, you have to
understand what the basic
scientists are telling you about
the the work that they're doing.
When that data comes to the
clinician, so we have a service
Console service, where any
patient in the whole system,
their their physician, who has
seen the patient for your cancer
diagnosis, can do this can
request this test. And that goes
off to to a sequencing
laboratory. And that result
comes back to the doctor and
shared with the patient. But it
also comes back to central
location where there are experts
and those experts can help that
doctor interpret that result.
And they can do so sort of on a
case by case basis as the doctor
asked for help. So that's one as
we set it up in 2016, and then
been growing outwards from
there. There's a partnership
that we set up, we set up way
that the Prostate Cancer
Foundation came to us and
offered this partnership to do
intensive research efforts
around prostate cancer and
selected some VA sites to defund
to do research to clinical trial
research, to advance the
understanding of how to treat
patients that have different
gene changes in their tumors and
specifically for prostate
cancer. So that's led to, like
Bruce Montgomery at the
University of Washington and
Puget Sound VA and at red egg at
UCLA, and greater Los Angeles,
VA Medical Center have been
instrumental in developing this
network of sites that can help
test new theories about how we
can treat patients better with
prostate cancer that have
different changes. And they've
started up a couple of trials,
very cutting edge trials, asking
really great questions, and then
organize a group of these
different centers to work
together to combine their
patients. And to offer them
participation in a clinical
trial that not only my benefit
for them, but would definitely
produce information that is
going to help us know how to
treat every prostate cancer
after that. So that's how we got
started. And that's expanded now
to lung cancer. At this point,
we call a system of excellence
in lung cancer we started last
year, and some other activities
that we've launched in the last
two years to make sure that
there is a access to the best
cancer care possible throughout
the system. So one of the
challenges that we have in VA is
that our population is more
rural than the country as a
whole, significantly more rural.
So almost a third of veterans
who are enrolled in VA
healthcare live in rural areas,
and the options that are
available for them is not as
good, right. A lot of our rural
health care facilities are under
financial stress. Some of them
are just closed completely. And
so what we're trying to do is to
make sure that whenever there's
an advance that we make that
available throughout the
country, when we started in 2016
Our position on call If you
program this program, doing the
testing and providing expert
care, we tracked very closely
where the veterans were that
were getting that service. What
was happening to those veterans
and wasn't the same thing
happened to those veterans,
whether they live near cities
where they lived in more rural
areas. And that was a focus for
us, because we wanted to make
sure that we weren't creating
new disparities. In that, I
think we were extremely
successful in that regard, that
there was actually no difference
at all in terms of the
utilization or access to those
services. And we've taken that
to the next step, which is
actually having our expert
physicians available to provide
care for veterans wherever they
live. So we've set up a what's
called, we would call it health
Intel oncology service, which
uses telehealth, which we're all
very familiar with now, because
a it's COVID. And everyone's
doing it right. But we started
this before COVID. And we
actually had a plan, that has
just been accelerated
significantly, because there was
more understanding, I think, and
acceptance of telehealth. But we
are now able to provide an
expert physician to be part of
the care team for patients and
rural areas that wouldn't
necessarily have the same level
of expertise available for them
in their community. And VA is
a collection of relatively small
hospitals, right, we have a lot
of hospitals, but none of them
are huge hospitals, compared to
some of the major medical
centers out there. So this is a
way that we can sort of collect
our different expertise and
deliver it where it's needed. So
when you have a patient with
colon cancer, you hope that that
patient would be seen by a colon
cancer expert. And that's what
we can do through the service.
So So I think what I'm saying
is, is that the the level of
precision also requires the
right people, right, you have to
have the right team members to
be able to deliver that, that
precision. And it improves the
efficiency. And the reduces the
cost, actually, when you have
people who really are expert in
that area, because they know
exactly what to do. And they
don't have to spend a lot of
time figuring out or reviewing
the latest treatments, because
they're, they're probably
contributing to them. Right. All
right. So that's it, that was a
long answer.
Shawn Spitler: You actually kind
of bled into my next question a
little bit, which was can you
talk about how technology has
improved cancer treatment, and
my example I was going to bring
up was telehealth. But I also
wanted to talk a little bit
about 3d printing and maybe how
that's impacting cancer
treatment. And then if we have a
chance, we don't have to answer
this now or at all, depending on
kind of your experience with it.
But I'd like to talk about, if
possible, CRISPR, if you're
familiar with CRISPR, and if
that's going to have any
implications in the future. And
then I think they're called
adjunct treatments, things that
kind of help help the existing
cancer treatment, like fasting,
I've heard a lot about fasting
and how that can help the
patient not have as severe
symptoms during during their
treatment. So maybe you can talk
about some of those things.
Unknown: radiation oncologists
have many different three
dimensional considerations and
their treatment planning. You
know, they use beams of highly
charged or highly energetic
arrays, if you will, or
electromagnetic magnetic fields
to deliver energy to certain
regions of the body. And it may,
there may be some consideration
there, and then it's in terms of
rehabilitation. So this is a
part of oncology is that when
you have some type of treatment,
you might lose some
functionality. And then there's
the undergo rehabilitation. So
there may be some role there for
3d printing. CRISPR is actually
a really interesting and very
powerful technology. It's, it's
basically gene editing, and you
can do it in whole cells and
maybe living organisms. And this
is part of something that might
happen in oncology. But it has
some limitations. So, gene
therapy for cancer is not a new
concept, right? We what we do
now is actually some form of
gene therapy, not that we change
the genes, but we understand
what the genes are, so we know
which molecules to use. So small
molecules that are not gene
changing molecules like CRISPR
is but they interact with the
proteins right. So so we're all
about proteins mostly right are
all the functionalities that If
that happened, our muscles are
proteins, the genes have the
instructions in them that gets
made into the proteins. And so
what what we're doing more so is
is understanding the gene
changes, and then using a drug
which interacts with proteins,
mostly. Okay, so what CRISPR
would do would be to actually
change the genes so that it
would change what protein has
been made. The trick there is,
is that you have to basically,
you have to change almost every
if not every cell, and the
efficiency of CRISPR is not
100%, or even close to it,
especially in human beings, I
wouldn't think that it would be
even close to that. So it's
used, I think, it has been used
successfully for genetic
conditions where if you change a
few cells, that's enough to be
able to give you a little bit of
functionality where before you
didn't have any, that lack of
functionality was causing a
disease. But in cancer, I, I
can't see that CRISPR is going
to be used in a therapeutic way.
But no, don't maybe just not
imaginative enough, or don't
understand the technology
enough, it is a very powerful
tool for preclinical work.
Because now what you can do is
you can go through and say,
Okay, here's a cancer and it has
this gene change, you can go
through and basically knock out
every other gene in the whole
cell and ask which ones interact
with that gene, right. And this
becomes a very powerful tool. So
this is this is a, an
interaction, which is used
therapeutically all the time. So
for example, going back to
prostate cancer, there are a
group of genes that control a
certain back out method of DNA
repair called homologous
recombination. So that those
that group of genes, if you have
a defect in any one of them,
your cells are not as good at
fixing certain DNA strand
breaks. And but they they do,
okay, because there's another
pathway, which is called Park.
And that pathway is is able to
fix that the DNA well enough.
But if you have a drug that
inhibits that, the parts it's
called a PARP inhibitor, then
those two things together cause
the cells to die. Okay. And this
is exactly what is happening in
prostate cancer. So there's a
fraction of men who have either
inherited or acquired in their
tumor cells, a defect in one of
those genes in the homologous
recombination set, and their
tumor cells grow and their body
grows and works, okay. But if
you give them a drug that
inhibits the PARP pathway, then
their tumors die, but the rest
of the cells say, Oh, I'm still
okay, because I don't have that
mutation, or I don't have as bad
of a mutation in the in the, in
the homologous repair gene. So
that and that was that can be
discovered by CRISPR, right? So
you can go through and find out
which other genes interact with
each other. And so this can be a
very powerful there are many
other ways that crispers use.
Alright, so CRISPR, so you did
3d printing CRISPR that facet,
okay. So, nutrition as a method
of managing patients with cancer
has been done extensively. And
the if there are any effects,
they are modest or
imperceptible. So it was a way
of treating cancer or treating
patients with cancer, it's not
clear that that is very useful.
That said, if you have cancer
and you're losing weight, that's
a bad prognostic factor, right?
But that's not something that
that you can necessarily change.
And if you try to change that
even by giving people like
intravenous therapies,
intravenous nutrition, I mean,
that also doesn't really help.
But nutrition and cancer
development, so that sort of
risk of getting cancer and
nutrition. Are there some really
classic examples of how those
interact. So first of all,
calorie limitation so it's
basically Starvation is a great
preventer of cancer during the
Second World War, when there
were many, many people who were
starving vein, cancer rate went
down dramatically. And how that
works is not entirely clear.
Some of them are related to, to
hormonal therapies. So some some
hormonal therapies are very hard
hormonal mechanisms. So for
example, like breast cancer,
maybe we have more more fat
tissues that increases the
production of certain hormones,
including estrogen, and that can
stimulate breast cancer
development. But I've not heard
about interaction with fasting
and side effects of cancer
treatments. Could be I don't
know.
Shawn Spitler: Fair enough.
Thank you so much.
Katie Delacenserie: You
mentioned this a little bit, but
can you talk about kind of just
in general, what it's like for
you to work with veteran
patients? And, you know, you
mentioned that rural urban
divide, and how you have worked
to kind of make a loving level
playing field. So can you just
talk a little bit about the
veterans, you you see on a on a
basis.
Unknown: I mean, I, I've worked
with veterans, for a long time,
I enjoy all the interactions
that I've had with veterans and
sort of feel like I'm, like,
maybe a groupie, right? Because
it's like, I was in the Public
Health Service, which is one of
the uniformed services, but I
wasn't in the military, right.
So I'm sort of like a hanger on
in that regard. But I've
interacted with with veterans
for a big part of my, my life,
right. So starting from medical
school, and worked in the VA, in
Ann Arbor, and then residency
here in Durham, and I was at the
heavy hospital and as a
Maryland, before it became
Walter Reed, including during
Desert Storm when they were
deploying. So I've interacted
with a lot of different people
and different parts of the
military career, both in the
Department of Defense and on va
quite a bit. But I think, you
know, for me, it's been probably
the most rewarding part of the
career that I've had is, is
interacting with veterans by
telehealth because it allows me
to be able to share my expertise
with people who probably
wouldn't have an opportunity to
benefit from that. And first of
all, as a group, I mean, you're
very respectful and thankful.
And there's nothing that makes
you feel better when you can
help somebody out and somebody
who, who you sort of have a
connection with, and sort of
makes you feel like, Hey, this
is this is really this is what
life's about right is helping
other people and being part of
something which is bigger than
you. And that's what I really
feel like when I'm participating
in this program is that this is
a big operation that we're
putting together. And the reason
we're doing it is because of the
people we're connecting with, on
the other hand. So that's,
that's been one of the most
satisfying things that I've done
is a physician,
Shawn Spitler: using that as a
jumping off point, can you tell
us about some of your successes
that you've had
Unknown: lots of successes,
right, so first of all, you
know, I told you some of this in
terms of the precision oncology
program when we launched that in
2016, to basically go from zero
to 60, in less than six months.
And in terms of being able to
provide access to the service
really quickly, and to do it in
a way which is comprehensive and
at a very high level. So that
was one area of great success, I
would say getting the different
components of the VA to work
together, right, because VA is a
big organization and oncology
touches on many of those and
sort of to have some
coordination between the
different partners that we work
with. So I already mentioned
surgery radiation, but we there
are many other medical
specialties and then we've had
great support and and insight, I
would say from our colleagues in
the Office of Research and
development and to be able to
help to launch a initiative,
which is now going to touch a
huge number of veterans. So part
of what we've done in lung
cancer precision oncology, as I
mentioned earlier that we, we
don't do screening, but we
decided that there was one area
where we needed to do some
effort and screening, and that
was lung cancer, because they
have a number of patients who
are getting access to lung
cancer screening was way too
low. And so we decided that we
need to try to to jumpstart that
initiative. And I think we've
been pretty successful at
getting that started. It's, it's
still has a ways to go because
we're talking about hundreds of
1000s, if not, over a million
trends, who would have no
consideration for possibly
getting screened for lung
cancer. But the infrastructure
that we've put together in
really less than a year, to be
able to do that type of work is,
is been coming along so nicely,
and get the different experts
and, and really, this whole team
together across the entire
country, right? To be able to to
offer that to veterans and, and
have a plan to get there. That's
been a huge, I think that's a
huge success. So so I can't say
right now, it's a success,
because the patients haven't
gotten it yet. But I can tell
you that it's going to come in
the very near future, and so
that the work that's gone into
putting that together has been a
great success. So I think that's
something we've we're now
amplifying our talent oncology
service. So we started and a few
other people started around the
country. And now that's one
nationalized service and works
with medical centers across the
country. But that is really
starting to roll as well. So
we're up to about, I think we're
working in about 10. Different
facilities now are expected to
be in twice that many by the end
of the end of the calendar year.
And then next year will probably
continue to expand. So that I
think is a huge success that
we've been able to, to grow at
such a great rate. And, and to
fill in demand as best we can,
while we are far more expanding
what else? There's so I mean, I
think in my sort of, I guess,
role as the, as the National
Program Director, I think one of
the things that that I always
think about is is how we can
contribute to the national
effort as well. And there are
some efforts within VA that I
think are huge successes. And
some of those are being able to
contribute data. So one of the
methods that we use to help
accelerate discovery is is to
share our data with others so
that they can look at it and
look at for new insights. And I
think we're making some great
progress there. As well, in
terms of making our data more
available so so that individuals
can can study it. So we look at
it but you know, we're they're
different
insights, ideas that can be
tested in the data that is
available in VA. And that's
something that I think we are
very happy to be able to share.
Because that that data is can be
very valuable to understanding
how to treat the next veteran
who walks in, or the next
American who walks in somewhere
else.
Katie Delacenserie: So VA has
been researching and studying
cancer for almost 100 years now,
that program began in the 1920s.
What does it mean to you to be a
part of that tradition? And kind
of reflecting on that? What is
What are you excited about for
the future?
Unknown: Wow, yeah. It's quite
humbling actually, to think
about the discoveries and the
work that went before some of
the seminal clinical trials had
been done in VA. I think what I
hear from my research colleagues
is that the first is multi site,
clinical trial was done in VA. I
remember learning ins in my
training program, some key
clinical studies and, and they
are They were called the VA
study There was a VA cancer
study group at one point. And in
small cell lung cancer, for
example, there's a staging
system that is called the VA
staging system that's still used
clinically, in terms of the
practical manner. So I think
that's something that, again,
helps you understand how you are
part of something that's bigger
than you are when you work in
VA. It's in some ways, it's I
wouldn't say humbling, but more
almost daunting, right? To think
of, okay, here's how am I going
to make an impact and everything
like this? How can how can you
possibly contribute to something
where there's all this storied
past and all of this history
that went into it, but when you
when you break it down, it's
it's it's our everyone can make
a little bit of progress. And
it's that little bit of progress
together, that moves the VA and
the VA oncology efforts forward?
It's not it's not like one
person who's who drives this,
right. It's, it's a, it's a
group effort. And Rachel rimoni,
who's the head of the Office of
Research and Development at VA,
it says over and over again. And
I always like it when she says
it, because she said it was such
a nice, cheery voice is, you
know, teamwork is the dream
work, right? Teamwork makes the
dream work. And so that is, I
think the, what really is
happening here. So that I see
more of that in the future. As
we come together to try to lay
out what it is we want to have
happen to veterans. So this is
extremely important is that you
have to have some plan for what
you want to happen to veterans
when they come in with, with
cancer, that the ecology field
is is quite complex. And it's
changing rapidly. And those
changes can't happen across a
big system like VA unless
there's a plan. So I see that
we'll be doing more of that as
that we'll be using our experts
to help provide recommendations
for what should be happening
more frequently. And then we'll
try to build a system in which
we can provide those pieces of
advice to everyone across the
entire system through electronic
health record tools, which
provide decision support, it
doesn't replace the physician in
any means, right. So there's no
cookbook for medical oncology,
there's no cookbook for how to
take care of patients with
cancer, you need to have some
individualization and that
happens through through the
provider team. But there there
should be some plan as to what
usually happens. And if there's
variation in that, and and I
think that's an area for for
improvement, that where we can
look at that and say, Well, why
is that is that? Don't because
there's something biologically
different between different
patients is that it was just
something between their tumors
or is this or there's knowledge
gaps are just practice
differences. Anyway, so I see
that, that VA will continue to
move in, in a innovative fashion
that is little steps here and
there and not huge jumps, right
that I don't think that's the
way you're going to see things
change. There's been a huge
change in
the immunotherapies. So we
didn't talk about this, but
immunotherapies have really had
a huge impact. And you can say
that, okay, well, 10 years ago,
I didn't see that coming. I
don't think anybody saw that
coming in, not too many people.
And that, that that change is
something that we were able to
rapidly adapt to and implement.
And that's what we have to be
prepared for. Because we don't
know what's coming next, there
will be advances. You can we can
go through it, we can go through
CRISPR we can go through
proteomics, we can go through
metabolic, metabolic monks,
metabolic omics, and in every
other form of possible advance,
but what actually comes forward,
you can't really predict and how
it comes forward and how you
implement it. Or those are all
very important thing. So I think
it's really important for us to
be prepared to have the system
to be able to implement whatever
the best practices when it gets
here, and that's that's where
everyone can play a role.
Shawn Spitler: Well, Dr. Michael
Kelly, thank you so much for
joining us on our program.
Katie Delacenserie: Thank you
very much.