Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Hilla. All right, this is Senate Health and Welfare. We're back on March 26, and we have the pleasure of having the Vermont Cancer Center director here, which is great. Doctor. Gulick, thanks for being here and giving us information about your work with the World Health Transformation Grant. They're gonna be very useful.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Well, thank you so much for having me here. I really appreciate the opportunity to come talk to you a little bit about what we're doing across the state of Vermont and what we're doing to try to improve rural health care, specifically for cancer patients and patients that are better at risk for cancer. I wanted to go just through a few different programs that we have either that are have started and are currently ongoing and that we're we're building, and another program toward the end that we're just about ready to start. So all things that are that are in the early phases of implementation or are sort of shovel ready to get to get done. The first first thing I wanted to talk to about is on the first page of the handout here, and that's that's really what we're doing with our outreach and education there. We were fortunate to get the philanthropic dollars to buy a van and to be able to outfit that both as a global laboratory and as a community outreach engagement van. So this van really serves two purposes. One is the it serves as a biomobile laboratory. We bring the van out to rural high schools, and and we introduce really cool science to the high school students. And the van is out there so that we have a fluorescence microscope inside the van. We have can do DNA electrophoresis so we can look at different particles of DNA and show how you can separate that on a gel. These are things that the high school students are really not exposed to. Our hope is that we motivate them to be our next generation of cancer scientists and cancer clinicians. And in addition to just showing them what's going on, we actually have an entire curriculum. We work with the department of education, the Vermont Department of Education. We have an entire curriculum for the students and also for the science teachers in those rural high schools so that we bring the sign teach science teachers, into the cancer center, at the University of Vermont. We show them, through the laboratories. They get to experience this sort of hands on so that they can really bring bring this back to their students and professors. Question for you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Someday it might be fun for this committee to have a field trip to that lab. Oh, that was great. Could we do that?

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: That would be great.

[Sen. Virginia "Ginny" Lyons (Chair)]: Absolutely. Can we think about that? Yes.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Yeah. We would love to do that. Yeah. We would love to we can we can you can do the field trip here. We can bring the band back here to do that. Would be awesome. Or or we can we can go out go out elsewhere. For instance, you know, we've we have various times where we're going out to to high schools. I think in about a week, we'll be at Central Vermont Career Center in in Barrie. So so we we have different times. We're we we we want to get to every every county in the state of Vermont, and so we we have different high schools that have already signed up for sort of our first wave. And, you know, our second and third waves will be going out to other places.

[Sen. Virginia "Ginny" Lyons (Chair)]: So let's plan on that. And if it sorts out that we could do it while you're here at Central Vermont, that would be really good. Okay. It helps travel time.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: And our commitment here. Sure. Wonderful. Good. Thank you.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: The second thing that the band does is it it goes to community events really across the state. We we try to focus on providing support and cancer prevention and screening information for the entire state of Vermont and for six counties in in Northern New York. You see this map map here of that of that area. On this map, you'll see that there are little circles and there are numbers in them. That's how many times we've actually been there just in 2025. And every county or ZIP code here that's has a shade of green means that we've been touching individuals from from those areas. You can see on the right side of this first page that we do not do very well in Vermont in lung cancer screening in our rural communities, and we don't do very well in colorectal cancer screening in our rural communities. So these two areas are a really big focus of ours, to educate people about the advantages of screening and finding cancer early, and also to bring, as much as we can some home testing for cancer screening. We can certainly do that with colorectal screening. We can do that with HPV home testing, which we'll be launching this year. We don't have some the capacity to really do home screening for lung cancer at the moment, but we have scientists at the cancer center who are working on new modalities to try to develop new techniques for lung cancer screening that could potentially be done at home. And so we hope that all of these things will increase

[Sen. Virginia "Ginny" Lyons (Chair)]: We're gonna hear our perhaps through a lot of questions when we visit that lab.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Okay. That is wonderful.

[Sen. Virginia "Ginny" Lyons (Chair)]: Some of us. I wanna know which.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Don't think I

[Sen. Virginia "Ginny" Lyons (Chair)]: particularly know which.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Just a question, doctor. Is lung cancer was my understanding as smoking has decreased over time that the number of lung cancer patients has decreased? Is that actually true? The answer is yes and no. Like many things, it's complicated. So overall, the answer is yes. There's lower rates of smoking generally, and that has decreased lung cancer rates. The problem is the rates of smoking in our rural communities remains very high. The incidence of lung cancer and mortality from lung cancer from people who live in our rural communities is much higher than those who live in an urban center. And lung cancer remains the leading cause of cancer death across the state of Vermont and in the six counties in. So it's still a major problem. For people who are eligible for lung cancer screening because it requires people to go to a center where there's a low dose PET scan machine, usually requires a whole day, they miss work, they have to travel. The rate of screening for those who are eligible for lung cancer screening according to national guidelines is only about twenty percent. So we can do a lot of that. Alright. I wanted to if there's no questions about the van, the only other thing about the van

[Sen. Virginia "Ginny" Lyons (Chair)]: It's about the van.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Is that this year, we're planning on hiring an advanced practice provider, like a nurse practitioner or a physician's assistant, to staff the van because it will be really beneficial because that individual can then prescribe nicotine replacement therapy if need be for smoking cessation, can order fit tests for people and follow-up with their primary care providers. So we really think that that will expand the depth of activities related to dental prevention screening. On the backside here, I wanted to mention two things. We know that our health care workforce needs health, especially in our rural communities. This is especially acute for oncology care in our rural communities. The average age of our oncologists who are practicing in rural communities is about 65 years old. So they're gonna be retiring soon, and it's very hard to recruit people to come to a rural community if they don't come from that from that background. So one of the things we've done is we've expanded our training program from two fellows a year, or six fellows total, to nine fellows total. Those additional fellows are going to get specific training in public health. They're actually going to get a certificate in public health when they finally finish their fellowship. They're going to be rotating through rural oncology practices here in Vermont. What we'd like to do is get them the exposure to rural cancer care so that hopefully some of them will stay and be our workforce for the future. So this is a long term project, but we don't start while people are in training. We're not gonna find those individuals to practice in other rural sites.

[Sen. Virginia "Ginny" Lyons (Chair)]: So who are you picking? Are these residents you're picking? Is it the students?

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: So these are hematology oncology fellows.

[Sen. Virginia "Ginny" Lyons (Chair)]: They're already

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: So they finished internal medicine residency. They're doing trainees in hematology and oncology. And then we have them rotating through rural sites with oncologists that are still in practice. So right now, they're rotating through Central Vermont Medical Center. We also are setting up rotations at Brooklyn Regional Medical Center, and we're we're having discussions with Southwestern Vermont as well. Cool. So so that's

[Sen. Virginia "Ginny" Lyons (Chair)]: So it sounds like it's either a replacement or an addition if you can get folks to stay.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: We can get folks to stay. Yeah. People need oncologists in their communities. We don't want people to have to travel to Burlington for all of their care. We would we would like to do that, get them as much care close to home as we possibly can. The the other initiative is that I have listed here is initiative number three, and that's really, we are thinking of reimagining how we do rural cancer care. We have a lot of patients from rural communities who come and get them care at the cancer center in Burlington, and that's great. But while they're on active treatment, very often their primary care providers in their local communities are uncomfortable caring for them, because they have cancer, they're on chemotherapy or immunotherapy, and they don't really understand what all the ramifications it's had are. Patients often will have issues. They'll call their primary care office and they'll get referred and have to travel to Maryland to see an oncologist. What we would like to do is set up an infrastructure to support those primary care providers in the rural communities so that we have someone always on call for them when patients need assistance that can provide the kind of oncology expertise to help manage patients and allow them to get as much care as possible close to home from their providers that they're used to having before they've had cancer. So this is really a new transformation. It requires infrastructure. It's going to require a lot of trainings. We've already started training sessions with primary care providers and with nurse practitioners from primary care offices to teach them a little bit about the side effects of chemotherapy, what to look for, what the problems are, also about screening and prevention. So this is really a comprehensive both educational initiative and also developing an infrastructure of support for our primary care providers across the state.

[Sen. Virginia "Ginny" Lyons (Chair)]: That actually fits with the blueprint beautifully with the chronic care initiative.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: I think it absolutely does. This is something we haven't quite started yet. We hope to launch that this year. As I said, this is a shovel ready project that I think will really benefit patients, will also benefit our primary care providers in providing additional support for them, and hopefully will reduce some of the stresses that they have and leading to retention so that we don't have so much turnover in our primary care

[Sen. Virginia "Ginny" Lyons (Chair)]: But that's lot too for reducing the need for hospital care and keeping people out into the community. That's one of the goals that we have embedded in our primary care bill we just passed.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Fits. My question about this is, it's a new program. I mean, sounds like it's a new program. And you asked to talk about Rural Health Transformation Program, but we have a Rural Health Transformation grant process. Are you looking to apply for this as a new program through the grant? Is that something that you're working with, AHS?

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: So, so I would say it's a new program, but it's already started. So we've already started our educational, components of this, our educational, portion. We did we did when before the the grant went in to to CMS from the state. Yep. You know, I submitted all of this information. Think it was specifically included in that. And I'm certainly looking out for the request for proposals as they come out to see what we could potentially apply for for this program. Absolutely. I think that this fits exactly in the model of rural health care transformation. And I think that it's something that will really benefit cancer patients in our rural communities and provide the sort of academic expertise that we can provide from the cancer center for the lab patients to get more vet care close to home. So the answer is absolutely yes. I think that it's a great fit. I hope that people who are reviewing applications like this also think it's a great fit because we would love to do this program. It's going to benefit our patients in the long run and in the short run. You took some testimony on biomarkers. Yes. Senator Cummings reported on the floor. Yes. And again, the way I understood it with some of the testimony, you can look, you can screen. Basically, if we're looking at different types of cancers and then you should know how to better treat that form of cancer and take It's it like like we're gonna try, at some point, try to move that forward. You know about it, obviously. Do you think it's a good We use biomarkers routinely, so the answer is yes. I think perhaps what has come to your attention is legislation to make sure that there's coverage for testing for biomarkers. I know that's a big priority of the American Cancer Society Action Network, Alzheimer's as well. It's absolutely crucial for cancer care today. So I'm a GI oncologist, a GI medical oncologist, so I only see patients with gastrointestinal cancers. I see a lot of patients with pancreatic cancer blood sample. About ten to fifteen percent of patients with pancreatic cancer have a BRCA mutation, a BRCA mutation, that is normally associated with breast cancer, but also increase the risk of developing pancreatic cancer. Drugs were developed that can be used for breast cancer patients, specifically who have BRCA mutations. We can use those drugs in pancreatic cancer as well. We cannot use those drugs unless we do the genetic testing to make sure that we understand who's going to benefit from that kind

[Sen. Virginia "Ginny" Lyons (Chair)]: of treatment. It's a BRCA1.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: It's mostly BRCA2, but it can be BRCA1 as well. So we need to do this testing. It's routine. I would say that most of the time we get the testing covered, but we do get pushback under, especially for some diseases where there may not be as much of a depth of literature showing its benefit. I take care of patients with biliary tract cancers. There are three or four different genetic mutations where there's a targeted therapy available for those mutations when they occur, but they occur in a small proportion of patients, maybe five to ten percent. And so sometimes in those cases, insurance companies will push back and say they don't want to do the test of the disease. The other thing that's fairly new and that we use for colon cancer, but it's going to emerge in other diseases as well, is that we can do biomarker testing for something called circulating tumor DNA. So when people have cancer, some of those cancer cells die, they release the DNA, and we have sensitive techniques where we can actually find that DNA circulating in the bloodstream. We know that if we find high levels of circulating tumor DNA, that have a significant burden of cancer. After they've gotten treatment, if that circulating DNA goes down to zero or undetectable, we may be able to stop treatment, which would lower healthcare costs. But we need that guidance from that kind of a test. Otherwise, we're probably just gonna continue treating people with chemotherapy that have more toxicity, the costs will be higher. So that's another form of biomarker testing that we're now using for colon cancer. But soon, I think we'll be using for other types of cancer as well. Okay. We need coverage for that because if we don't have coverage, we can't make those sort of, what I would call personalized directive therapies. I was hoping that, yeah, I know it's a big investment, but I'm hoping that the other end you have more savings, right? Think in the end, testing will actually save money. I I think the insurance companies are looking very short term. This is an expensive test. They don't want to pay for it. If I can stop chemotherapy and not give several months of chemotherapy, it's going to save the insurance companies a lot of money. And costs we're coming down, too, right, on biomarkers? Is that

[Sen. Virginia "Ginny" Lyons (Chair)]: not testing, some of them are, right? Yeah.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: The testing is, well, let me put this right, it's a lot less expensive than a casting, or an MRI scan, which they routinely approve. It's just like screening for cancer. Screening costs money. You have to invest in that, but you're gonna tenfold reduce the amount of healthcare costs because you're gonna find cancer early, and the cost of treating cancer early is much less than when you find it at a later mass. And

[Sen. Virginia "Ginny" Lyons (Chair)]: it better for the patient.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: And a whole lot better for the patient.

[Sen. Virginia "Ginny" Lyons (Chair)]: This is terrific. So we're getting a preview of what we're going to ask and learn about in the lab.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Yeah, she's invited, that's exactly right. So I think all of these programs fit under the mission of rural healthcare transformation. Obviously, it's very focused on cancer patients. I'm a cancer center director, so that's where my focus is. But rural patients are 20% more likely to die from cancer than people who live in an urban community, and that's just not right. And we should be able to address that, And we can address that if we do the right things and we provide the right kind of support for both the patients and their providers in rural Right, that is correct.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's right. We've got it. This has been great. So this is the tip

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: of your

[Sen. Virginia "Ginny" Lyons (Chair)]: iceberg and we look forward to taking our field trip. And I want and we're going to be taking testimony about the grant, the whole RHD. And I'll be sure to look for this and how applicable what's going out with the RFPs. I under I'm not sure all the RFPs are going out. So it's a little bit behind from my perspective, but we'll see what we can do.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: I've only seen three come out so far. So so, you know, I'll I'll continue to look for that. And and we're, you know, we're we're always looking for other sources of funding for to do these projects because we think that they're very worthwhile. We will be submitting later on this year to the National Cancer Institute to try to get the National Cancer Institute designation grant, and that'll provide some funding as well to help support some of these programs. And I think that will, the the downsides of that, which are positive downsides, upsides of that, the upsides of that are that it once we get that, it will also help us recruit the best clinicians and the best scientists to Vermont. And that's what we want.

[Sen. Virginia "Ginny" Lyons (Chair)]: So

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: at some point in the future, we will likely ask the health committee here to provide a letter of support for that submission, which we hope we do in September. We'll be glad to do that. Let us know, and we'll grasp something up and endorse even Thank you. I think the main, if gave you one message today, it's that the cancer center is very focused on our rural communities here in Vermont, and we want to address the disparities in outcomes for cancer patients in our rural communities. Think that some of the efforts that I've described here today will address that, at least in part, and we want to keep generating new proposals and new projects that will do that even better. Thank you. Really, this has been terrific. I really appreciate you taking the time. You gave me a lot of time on your schedule. This was

[Sen. Virginia "Ginny" Lyons (Chair)]: We have.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: This was really wonderful, and I

[Sen. Virginia "Ginny" Lyons (Chair)]: appreciate It's important for a lot of different reasons. And so we appreciate the knowledge that you bring and the work that you're doing. And then this informs our work. So thank you very much. Appreciate it.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: And we look forward to setting up a an. Oh, that's right. I'm right here. It's a it's a school a school trip. We don't

[Sen. Virginia "Ginny" Lyons (Chair)]: turn that by the middle school trip.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Right. Either either either when we're going to one of the high schools or or we'll we'll we'll bring the van down here to

[Sen. Virginia "Ginny" Lyons (Chair)]: My gosh.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: To the legislature and and show you all the stuff that's

[Sen. Virginia "Ginny" Lyons (Chair)]: going on. If it were here, you would be overwhelmed.

[Dr. Randall F. Holcombe (Director, University of Vermont Cancer Center; GI medical oncologist)]: Yeah. Everyone would

[Sen. Virginia "Ginny" Lyons (Chair)]: be interest. Yes. Because even Troy would come in. Uh-huh. So we're gonna call it a wrap. We're gonna go off live, and thank you very