2 – Early Cancer Detection for Veterans
November 11, 2022

Many U.S. veterans may be at an increased risk of cancer, making access to early detection critical to their health. Dr. Charles Atwood, pulmonologist and lead researcher for the REFLECTION Study at the VA Pittsburgh Healthcare System, joins The Cancer SIGNAL to discuss the work being done to expand early cancer detection for veterans.


Kim Thiboldeaux  00:08
Welcome to The Cancer SIGNAL, a new podcast presented by GRAIL, where we discuss the impact of early cancer detection, the science behind multi-cancer early detection and insight into how this approach has the potential to shift the cancer paradigm. I’m your host Kim Thiboldeaux.

Earlier this summer GRAIL announced a groundbreaking collaboration with the US Department of Veterans Affairs and the Veterans Health Foundation to provide the Galleri multi-cancer early detection blood test to 10,000 veterans over the next three years in 10 participating VA sites across the country. The VA Pittsburgh health care system was the first to announce its participation in the study. In recognition and appreciation of our veterans, we are pleased to be joined today by Dr. Charles Atwood, pulmonologist and lead researcher on the REFLECTION study at the VA in Pittsburgh. Welcome to the show Dr. Atwood.

Dr. Charles Atwood  01:04
Thank you, Kim. It’s a pleasure to be with you.

Kim Thiboldeaux  01:06
So, Dr. Atwood… please take a moment. Tell us about your background and how you came to be a researcher at the VA in Pittsburgh.

Dr. Charles Atwood  01:15
So I am a pulmonary medicine physician. And I’ve been at the VA Pittsburgh my entire career, over 25 years. I also worked for the University of Pittsburgh and UPMC as a pulmonary physician there. Over the years, my research interests have focused on a couple of different areas. But the one I’ll talk about today is the area of lung cancer. In the year 2000, so 22 years ago, I was the division head of pulmonary medicine at the VA – I was very young in my career. And I was noticing that it was taking what I thought was an excessive length of time to get patients with lung nodules evaluated appropriately, these lung nodules, in some cases may represent an early cancer. And it would take, you know, too long…two months, to get this worked up. And I felt we could do better. So we made some changes to our process, hired a nurse practitioner to help with it. And 22 years later, we’re still doing the same lung nodule program. And we have expanded it to the lung cancer screening programs that many of your listeners may be familiar with, the VA is a real leader in lung cancer screening. And then that led me to be interested in multi-cancer early detection, such as with GRAIL. And GRAIL came to the VA 18 months, maybe two years ago, wanting to strike a partnership. And the central office research establishment of the VA recommended Pittsburgh as one site to look at for leading that study. And that’s how GRAIL and Pittsburgh got together. I was asked to look at the leadership of the study, and I was happy to do it. And after thinking about it for literally like two minutes, I said this is a no brainer…I definitely want to be involved in what I think is a big part of the future of cancer medicine in the US.

Kim Thiboldeaux  03:26
Wow. Fantastic. That’s a great background. Thank you. You know, Dr. Atwood, perhaps…perhaps we all think we know the answer to this question. But what is the mission of the Department of Veterans Affairs?

Dr. Charles Atwood  03:40
Yeah, the mission of the VA is to take care of veterans, men and women who have served our country in times of conflict and in times of peace, to offer them the best health care that the US has to offer. Taking into account the often very unique circumstances that veterans find themselves in whether it’s due to illnesses or injuries during military service, or they’re sometimes post military careers that have been impacted by the time they were in the military. So veterans are our neighbors, our friends, our family members, our loved ones, but they also have a special contribution that they have made. And sometimes medical problems as a result of that contribution. So that’s, that’s the primary mission of the VA. The VA also has missions around research, around education, and in times of national crisis, to backup the private sector in delivering healthcare and actually the VA played a very major role in the COVID pandemic response in the US by helping by backup private sector hospitals that sometimes were over overwhelmed.

Kim Thiboldeaux  05:04
Wow. That’s a great, great context for where we are today with some of the the issues that we’re facing. Doctor Atwood, how many…let’s get to some numbers, how many veterans does the VA care for each year, there for example, in the Pittsburgh location?

Dr. Charles Atwood  05:18
So in the Pittsburgh location, we, we have about 75,000 veterans enrolled with us the number is up and down a little bit every year, but around 75,000. But we think, not so much even locally anymore. We really think regionally. And if you look in the whole western Pennsylvania area, which has four VA sites, Erie, Butler, Altoona and Pittsburgh, each of those other three sites also has about 25,000 veterans that they take care of. So if you add our whole region together, it’s around 150 to 160,000 veterans that are cared for at one of our four centers in this region.

Kim Thiboldeaux  06:04
Wow, some talking about some big numbers there. I’m here in Philly on the other end of the state, just FYI. Dr. Atwood, we know that the data shows us that veterans are at elevated risk of developing cancer. Why is that the case? Does it have to do with exposure to burn pits, to other toxic substances? Other factors that we should be aware of?

Dr. Charles Atwood  06:31
There are a lot of factors that go into putting someone at risk for developing cancer. Certainly, in the case of veterans, military exposures to burn pits to other toxins, a lot of which have been in the news lately, are one factor. Veterans, as a whole are older than the general population, and the number one risk factor for developing cancer is age. Veterans have been, in the past, have been heavy cigarette smokers compared to the general population – so that’s a factor. Fortunately, veterans now are really no more likely to be a heavy smoker than anybody else in the country. So there’s there’s a lot of factors that go into it. And those are just some of them.

Kim Thiboldeaux  07:20
Got it. And he talks about the burn pits being in in the news over the past few months. I think part part of that was because the PACT Act was signed into law. The PACT Act, in summary, expands VA health care and other benefits for vets exposed to burn pits, and other toxins. What’s your view on whether the PACT Act will help vets with cancer, and will it helped with our efforts to detect cancer in earlier stages?

Dr. Charles Atwood  07:45
So the PACT Act is going to do a lot of things for the VA or for veterans, the VA, you know, it remains to be seen exactly what impact it will have on the VA but very likely. And the expectation is that there will be a lot more veterans that seek to get their care through the VA, because this will be a kind of a natural entry point into that health care system. I think veterans will benefit from the PACT Act. In terms of cancer, the REFLECTION study, which we’ll talk about in multi-cancer early detection is only going to increase in the VA, I think. I think the PACT Act will be part of that. I think it will lead veterans to understand that they have a significant risk factor for cancer, and many of them I think will take advantage of programs that the VA has to offer in terms of getting early detection and treatment if cancer is found and getting state of the art treatment here.

Kim Thiboldeaux  08:49
That’s that’s terrific to hear. And I know we’ll learn more as the administration of this fund unfolds and look to keep in touch with you about that. Let’s turn Dr. Atwood to the study with GRAIL, it’s called the REFLECTION study. You mentioned at the top of the show that you fairly early on took a took an interest in in MCED, multi-cancer early detection sounds like you’re a little bit ahead of the curve. So I’d love for you to tell us about the study. I mentioned that 10,000 veterans will receive the Galleri multi-cancer early detection test at 10 VA locations across the US. Tell us how you’re offering the test in Pittsburgh, kind of walk us through the mechanics of it if I’m a vet walking in, how does that work? And have you seen any positive signal positive results yet?

Dr. Charles Atwood  09:34
Yeah, the way REFLECTION works, is you’re right, there will be 10,000 veterans enrolled across the country through VA sites, probably around 10 sites. That’s the that’s the number we anticipate in leading this study is will last the enrollment in the study will last three years and then there’ll be a follow up phase. The way veterans can access the study is through their local VA site that’s participating through their primary care clinics, this is very much a primary care facing study. So we are working at Pittsburgh, we’re working with our primary care teams to introduce the study to get their practitioners interested in participating, to get their patients interested in participating. The patients, the way it will work, is the patients will see their primary care provider for a visit. You know, maybe an annual health wellness visit, bring up the study. The patient can bring it up to the provider, the provider can bring it up to the patient. If there’s mutual interest, they alert one of our research coordinator staff, and we will meet with the patient, our coordinator will explain this study, if the patient is still interested enroll him or her and send that patient to get the blood draw, which is the basis of the Galleri test. Galleri is the name of the tests that we’re using, through GRAIL for multi-cancer early detection. The test is just a simple blood…blood draw. It gets sent, the tube of blood gets sent to the GRAIL laboratory, where it’s processed. And then in about 10 days, the result is sent back to the patient through our research study apparatus, the patient’s notified by a letter of the result. So far we’ve enrolled around 12 patients, we’ve only been up…we’ve been open for enrollment for about three and a half weeks now.

Kim Thiboldeaux  11:44
Right. If a positive signal were detected in the VA system through one of those patients, I’m assuming then within the VA system, you have the capacity to do all the diagnostic work that needs to be done to confirm a diagnosis and then move into a treatment plan. Is that correct?

Dr. Charles Atwood  12:01
That’s correct, we are fully capable of evaluating any positive results. One of the nice things about the MCED, or multi-cancer early detection with GRAIL, is that the cell free circulating DNA that’s the basis of this test, also has characteristics that point towards the site of origin. And it’s not 100%, but it’s the data so far would say it’s about 90% accurate. So if it’s coming from the..the pancreas, it’ll point to the pancreas and we would begin our search for a tumor in that appropriate area. You know, there’s a, we would assemble a couple of different cancer and clinical experts in other areas to guide our, our planning and our workup for this, this patient with a proposal with a presumed cancer until we find it.

Kim Thiboldeaux  13:01
So I know you’re overseeing the site there. In Pittsburgh, we talked about the possibility of about 10 sites. So what what are your hopes for the broader national study? Are you talking to your colleagues at other sites around the country? 

Dr. Charles Atwood  13:12
Well, we have every week, we have one or two meetings with colleagues at different sites to see if they’re interested. Several have expressed a lot of interest, some have had interest, but then decided it’s not a good study for them. But I really have no doubt that by the end of the period for identifying sites that we’ll have 10 sites, and each of them will be up and running as quickly as they can and enroll veterans and you know, the whole study rollout will be similar as to what we’ve done in Pittsburgh. It will be primary care facing, every site does primary care their own way. There’s not a mandate that every primary care program be just like every other one. For this particular study, that however they manage their primary care programs, that will be the focus of the GRAIL and Galleri testing at the site.

Kim Thiboldeaux  14:15
Well, and for the most part for all of us, it mostly is our primary care doctor who refers us for other screenings, right, colonoscopy, etc. Dr. Atwood, how would you encourage veterans to participate in or take advantage of of this of this study? You’re sitting in a room with a veteran? How do you introduce it? What would you say to them replicate that conversation for me a little bit?

Dr. Charles Atwood  14:37
Sure. So let’s say I’m a primary care doctor, I’m talking to one of my patients, I’d say, you know, you’re, you know, Mr. Smith, you’re 55 years old. You’re in the age group where cancer becomes increasingly likelihood and a concern for you. The VA here in Pittsburgh is working with a company called GRAIL that has a blood test that’s used for early cancer detection. I would say that, you know, there, this is a really rapidly up and coming part of how cancer is detected. And only five of them have other means of screening. So you just wait till one shows up, and then you diagnose it when it becomes a presenting problem. But with this early cancer detection blood test, we have a good chance of detecting it early if it’s there. And the earlier you can detect the cancer, the better chance you have to cure it.

Kim Thiboldeaux  15:36
And the patient says, I don’t know Dr. Atwood that’s sounds a little bit scary to me. I’m not sure if I want to know all that.

Dr. Charles Atwood  15:43
well, I’d say cancer is always it’s a scary word. But if we…if there is one, and we did this test and detected it, wouldn’t you like to get that cancer detected and treated early rather than later, the earlier we can find it and treat it the better chance you have of a good recovery.

Kim Thiboldeaux  16:03
But Dr. Atwood I don’t have anybody my family has had cancer. So maybe I don’t need this test.

Dr. Charles Atwood  16:08
Well, you can always you can always refuse. But this is a, this is a test that’s not going to go away. We’re we’re going to be continuing to do this, I think really throughout the rest of my career, and it will only spread. So if you decide not to do it now, we can talk about it again next year, give you time to think about it, maybe read about it, talk to your family about it. But I think at some point, you might really want to consider it, it would be a good test for you.

Kim Thiboldeaux  16:35
Excellent. That’s great. That’s really helpful. Thank you. Sometimes it’s good to just put ourselves in the room a little bit, you know, see how the conversation might go? Dr. Atwood, why do you think it’s important to offer this test, particularly to veterans today?

Dr. Charles Atwood  16:52
Well, veterans have, as we talked about earlier, some increased risk for cancer. The VA is really interested in, you know, getting to their natural constituency, veterans, as quickly as possible, to deliver the best care as quickly as possible. And increasingly, if we have the ability to detect cancer at an early stage, that is going to be part of the way that we want to deliver high quality health care to veterans in the future. We want high quality healthcare to be, in some ways defined by finding illnesses early on. So we can intervene much more effectively than if we wait until the cancer has spread everywhere. And there’s nothing we can do other than make people comfortable, or give them treatments that are toxic and hard to take in order to give them some longer period of time of life. We really want to capture cancer early on, and get rid of it when it’s easier to get rid of.

Kim Thiboldeaux  18:04
I know we need to wait for the results of the study and see how we do with that, and I know there are other studies that are happening, you know, with this test, but what role do you think potentially multi-cancer early detection testing could play for the VA into the future? What could you imagine or see or hope for?

Dr. Charles Atwood  18:25
Yeah, but I can imagine is that five years from now when we have results from this test this study and it let’s say it’s been a successful study for the VA, the VA has learned a lot, GRAIL has learned a lot about how primary care doctors think about detecting cancer early. It’s become, at the 10 sites where this has been implemented, it’s become really kind of part of the primary care annual wellness visit where you get your lipids, your cholesterol checked, your blood pressure checked, your vision checked, and you get a early cancer detection test. So that if there is a cancer growing in your body, we have a better chance of detecting it early rather than later. I envision this will eventually just become part of the routine of primary care medicine in the US.

Kim Thiboldeaux  19:22
It’s great, that’s really helpful to to know and understand and see what the potential is here. Finally, as we celebrate Veterans Day, this month of November, and think about our veterans, you have dedicated your career to serving veterans. So what is your message to our veterans as we honor them this month?

Dr. Charles Atwood  19:40
We thank you for your service. We’re proud and honored to take care of you as patients. And we only want to do what is the best for your health. And in the case of cancer, we want to offer state of the art treatment, but we also want to offer a state of the art early detection for cancer.

Kim Thiboldeaux  20:02
It’s great. That’s great. Dr. Atwood, I want to thank you so much for joining us today on the show. We look forward to talking to you again as the study progresses, and we learn more about ways to support our veterans. This is The Cancer SIGNAL presented by GRAIL. I’m Kim Thiboldeaux, tune in next time to learn more about the impact of early cancer detection.


Important Safety Information
The Galleri test is recommended for use in adults with an elevated risk for cancer, such a those aged 50 or older. The Galleri test does not detect all cancers and should be used in addition to routine cancer screening tests recommended by a healthcare provider. Galleri is intended to detect cancer signals and predict where in the body the cancer signal is located. Use of Galleri is not recommended in individuals who are pregnant, 21 years old or younger, or undergoing active cancer treatment.

Results should be interpreted by a healthcare provider in the context of medical history, clinical signs and symptoms. A test result of “No Cancer Signal Detected” does not rule out cancer. A test result of “Cancer Signal Detected” requires confirmatory diagnostic evaluation by medically established procedures (e.g. imaging) to confirm cancer.

If cancer is not confirmed with further testing, it could mean that cancer is not present or testing was insufficient to detect cancer, including due to the cancer being located in a different part of the body. False-positive (a cancer signal detected when cancer is not present) and false-negative (a cancer signal not detected when cancer is present) test results do occur. Rx only.