By Katie Kerwin McCrimmon
ALAMOSA – Spires from 14,000-foot peaks jut up like sentries as the five-seater plane banks into Colorado’s remote San Luis Valley.
Below, at Great Sand Dunes National Park and Preserve, giant waves of sand crash into the base of snowy Crestone Peak, a wayward beach lost in the mountains.
Madeleine Kane, a Denver medical oncologist and hematologist from the University of Colorado Cancer Center, holds a stethoscope and two poetry books in her lap. She peers out the window as alpine lakes shimmer in the early morning light. Then she sees a quilt of mile-wide green crop circles from potato farms that signal her arrival in this sprawling valley and its largest town, Alamosa.
This 8,100-square-mile valley is as big as the state of Massachusetts. Yet there is no cancer specialist here. Poverty grips one-third of the children and 20 percent of the adults here. And while affluence has often bypassed this rural area, cancer has not.
So, three days a month, Kane flies in from Denver to see a full day’s caseload, Thanks to her visits, the patients get state-of-the-art care and access to the latest clinical trials without the added stress of a long drive to a city.
Kane has to leave home before 6 a.m., but enjoys the stunning flight through puffy clouds over jagged peaks. Only once has the weather forced her to cancel a trip. Her patients range from Mennonites who have recently settled in the Valley to descendants of the Spanish immigrants who have lived here for hundreds of years, before Colorado was a state.
“If we weren’t coming, they would have to travel or some wouldn’t get care at all. Some people will not leave this valley, particularly older people who have lived their whole lives here. They don’t want to leave,” says Kane.
A powerful support network here helps her patients fight cancer.
“They’re not rich. They are people who don’t have a lot. Yet, they have a strong cultural heritage and very strong families,” Kane says.
Doing more with less
Visiting specialists like Kane allow the San Luis Valley Regional Medical Center to do more with less. Kane is one of 15 doctors whose specialties range from oncology to neurosurgery and cardiology who travel from Denver, Pueblo and Colorado Springs to bring specialty care to this rural valley. The hospital pays the doctors and covers their travel costs. Kane flies on Colorado’s state plane, and the hospital reimburses the CU Cancer Center for the cost.
“We get access to the best-practice medicine. But we don’t have to employ folks (full time) who logistically can’t afford to practice here,” said Timothy Pellandini, practice administrator for the San Luis Valley Regional Medical Center.
Forecasting the changes now accelerating around the country, the center has for years offered what’s called an “integrated delivery system.” About seven years ago, the specialty doctors’ businesses were teetering on the verge of collapse. The Valley has always struggled to attract and retain medical professionals and could not afford to lose its specialists. So the hospital took over the private practices and now directly employs all of the specialty providers in the Valley.
Years before policy wonks identified integrated care as a promising health care delivery model, the San Luis Valley medical center was putting integrated practices into place. The concept brings preventive, chronic and emergency care under the same roof.
The resulting cost savings and better insurance reimbursements have stabilized salaries for medical practitioners, and the Valley is now able to retain more of its doctors.
“For rural medicine, we’re really well poised for the future. We’ve been in business as an independent community hospital surviving on a 2-to-4 percent operating margin,” Pellandini said. “We’re not able to offer everybody everything.”
But, the center works to offer the patients what they need most, including cancer care and a new full-service digital mammography center dedicated to a young San Luis Valley mother who died of breast cancer.
Providing specialty care is an especially striking accomplishment here given how few of the patients have private health insurance.
About 60 percent of the hospital’s patients are either on Medicaid or Medicare, with only about 20 percent having commercial health insurance. The rest are uninsured and must pay out of pocket.
“We’re running lean and smart,” Pellandini said. “We try to keep things affordable.”
Five years ago, the medical center opened an oncology and infusion center, allowing patients to receive chemotherapy close to home. Patients who need radiation treatments still must travel to Pueblo, but for many, receiving chemo treatments in the homey center is a huge relief. Many of them are Madeleine Kane’s patients.
Cutting edge care close to home
Kane steps off the plane at Alamosa’s tiny airport. The scent of freshly mown hay hangs in the air from a farmer’s field next to the runway.
A woman in scrubs is there to meet her. Brenda Gentile is the hospital cancer program’s patient navigator. She will spend her day doling out sympathy, helping patients coordinate their medical care and finding other services they need. For instance, if a patient has no health insurance, Gentile will hunt down free or discounted chemotherapy drugs. If others are struggling with bills, she’ll find a way to pay a car payment or help with rent.
“How was your flight?” Gentile asks.
Kane tells her about storms that brought inches of rain to Denver the night before, leaving the airport socked in and delaying takeoff by about 20 minutes. The pilot eventually found an opening in the clouds and now the sun is shining in Alamosa.
The women climb into a blue pickup truck. They drive into the heart of Alamosa, bumping over the railroad tracks and past the brick train station to a medical office building.
Gentile’s phone rings. A voice on the other end tells her that Kane’s first patient is ready for her.
So begins a day of back-to-back appointments. There will be no time for poetry, much less any breaks. Kane will grab lunch while writing notes on charts. One perk of the day is the view. Her office window frames Blanca, a 14,000-foot peak in the Sangre de Cristo range that forms the eastern boundary of the Valley. To the west, past miles of flat ranch and farm land, the wild San Juans tower in the distance.
“One of the things I love most here is being ringed by mountains,” Kane says.
Among the patients she sees on this July day is Joyce Maldonado, 54. She wears a black cap over a traditional bun on her head. She is one of the Mennonites who have settled here in the last 20 years. She lives on a small farm near the town of Center. Her husband, Joe Maldonado, 71 worked as a hunting guide for years on the giant Forbes Ranch, which was a wilderness playground for one of America’s richest families and now has a new owner.
Joe Maldonado is a descendant of the Spanish immigrants who settled the San Luis Valley in the 1850s under a Spanish land grant. Joe was raised Catholic and later converted to the Mennonite religion, which espouses humble living, simple dress and minimal technology.
Joe and Joyce married later in life. She used to be a nurse. Now, they run a business called The Pastry Barn, but Joyce has been too sick the last few months to bake her signature pies that are their top sellers.
Joyce had no health insurance when she was diagnosed with cancer. She is now on a program called the Colorado Indigent Care Program (CICP), which provides funding to clinics and hospitals so patients can receive discounted care.
“How are you feeling today?” Kane asks as she steps in to the exam room to see Joyce Maldonado.
“I’m feeling good, but sometimes I feel lightheaded and dizzy. Is that a normal chemo reaction?” she asks.
“No, it’s not. We could give you fluids,” Kane says.
Kane examines Maldonado, reviews her lab results and discusses her pain levels.
Maldonado’s battle began over the winter. She felt like she had an unending case of the flu.
“I was achy and feverish,” she said. “But we knew we could not afford to do a lot of doctoring. “
Eventually, Maldonado went to see an internist in Del Norte who checked to see if she had lupus or fibromyalgia. Tests kept coming back negative, but she didn’t feel better. The doctor finally honed in on multiple myeloma, a bone marrow cancer, and referred Maldonado to Kane. The cancer has caused a partial fracture in one of her vertebrae. So on top of the reactions to chemo, Maldonado is walking around with a broken back.
She rates her pain at about a five out of 10, an improvement over previous months.
“When I’m up working, it’s bad. I went to church for the first time in three months. After standing up and talking to everybody, I was pretty well had,” Maldonado tells Kane.
The cancer has decimated the couple’s business. Last summer, they were selling about 130 pies a week to restaurants and individual customers. Now Maldonado can barely summon the energy to make any pies.
“We have pretty well just quit the business,” she says.
The Maldonados have had to rely on church families and others for help. Brenda Gentile, the hospital’s patient navigator, has helped allay financial worries. Cancer drugs that would have cost $900 per treatment instead require a $7 co-payment. Gentile has found funds to help with some mortgage and car payments.
Church families have brought the couple food and tended flowers in the garden. First-graders from the church school came to sing during one of Maldonado’s chemo treatments. Tears well in her eyes as she thinks of that moment.
“My back was hurting and just then, they sang, ‘My Jesus has broad shoulders, His back is stronger than mine.’’’
Maldonado is about halfway through a six-month regimen of chemo. For the most part, she tolerates it well, but feels lousy every fourth treatment.
“I always hit a day when I wonder if I should press on,” she tells Kane.
She recalls one particularly tough time. She was in the pastry shop and became emotionally overwhelmed that cancer struck her.
“This darkness rolled over me. I thought, ‘How can this be?’”
Then, she said peace washed over her as she accepted a simple message from God.
“Just take one day at a time.”
Kane offers Maldonado emphatic encouragement to keep pushing through her treatments. She tells Maldonado that her lab results show she’s getting better.
“As long as we’re continuing to see improvement, we should continue to press on,” Kane says.
“The treatment is working?” Maldonado asks, almost surprised.
“Isn’t that wonderful?” Joe Maldonado says.
Joyce Maldonado stands up to leave and Kane gives her a hug.
“You really have such a calming, soothing effect on us. Thank you,” Joyce Maldonado says.
“It is so wonderful to be just a half an hour away,” adds Joe Maldonado. “With the price of gas and selling pies for just $10 each, we would never be able to afford to leave (the Valley for cancer care).”
Another young cancer victim reiterates that sentiment: receiving care close to home is critical.
“When you don’t feel good, where do you want to be?” says Carolyn Salazar, 50, who has been battling a rare form of lung cancer. “You want to be home with your own belongings.”
Salazar works in a building next door to the specialty care clinic. Instead of taking a full day off of work for her check-ups, she can simply walk over to see Kane.
“The closest place would be Pueblo. That’s still a 2 to 2 ½ hour drive. This saves me money and time away from work.”
On this day, Salazar’s blood work is “boringly normal.” Kane checks her oxygen saturation levels. Salazar proudly tells her doctor that she managed to walk in the American Cancer Society’s Relay for Life event the previous weekend in Alamosa.
“When I did my walk, I thought, ‘I’ve got to be doing this more often. Even though I’m on oxygen, it has to be helping my lung capacity.’’’
“We’ll just keep on keeping on. You look great,” Kane says.
“Next month then?” Salazar asks.
“You’re good to go.”
Beating the odds
The humble cancer patients in the San Luis Valley are receiving care from one of the top specialists in the region. The CU Cancer Center is Colorado’s only comprehensive cancer center as designated by the National Cancer Institute. There are just 40 of these centers in the country.
This means that when Kane flies to this rural valley, she brings with her expertise from consultations with colleagues along with the newest treatments and clinical trials.
As a young girl, Madeleine Kane thought she wanted to become a college professor. Then, she discovered medicine, a career that would allow her to teach and do research, but also to work closely with patients.
Kane picked oncology because she liked the challenge of facing a tough medical foe. Yet, she also works closely with people.
“I like taking care of the whole patient. In oncology, there are some aspects of primary care (medicine),” she said. “You’re really taking care of the whole family.”
Kane earned her medical degree from the University of Miami. She also has a PhD in biochemistry from the University of Maryland and did her specialty oncology training at Stanford and CU. She’s an expert in head and neck cancer, along with gastrointestinal and thyroid cancers. She’s also an expert at treating cancers associated with HIV. This is a personal passion. She had a brother who died of AIDS. Kane is the medical director of clinical research studies for the CU Cancer Center and is the chief of medical oncology at the Denver Veterans Administration Medical Center.
One of the greatest challenges for cancer specialists is knowing that a certain number of your patients will die, but colleagues sometimes call Kane the “optimistic oncologist.”
“I do get pretty close to many of my patients,” Kane said. “We often beat the odds. Our survival rates are better than (rates in) the region.”
While survival is a top priority, Kane is sensitive to her patients’ wishes. For instance, she treats a 74-year-old woman who is frail and doesn’t want to the leave the San Luis Valley for radiation treatments.
“She has decided not to seek this additional care. It’s a pretty grueling day for anybody (to drive out of town for radiation),” Kane said.
So Kane and the woman’s family have created a less aggressive treatment regimen.
“She seems to be holding her own.”
By day’s end, Kane has seen 18 patients, updated all of their medical records and charted a course for their future treatment. While she’s back in Denver, many patients will continue to get chemotherapy infusions at the medical center’s Oncology and Infusion Center. Primary care providers and other oncology team members can consult with Kane by phone or e-mail if questions arise before her next trip to the Valley.
By 5:30 p.m., she walks back across the tarmac, admires the view of Blanca and ducks into the small plane. Her pilot, State Patrol Trooper Will Sanders, has been checking for thunderstorms, which are once again predicted. There’s one far in the distance, south of Denver. But he thinks he can beat it home.
Kane leans back, slips off her shoes, puts her long legs up on a seat facing her and relaxes for the first time all day. She glances out the window as the plane ascends back over the sand dunes and heads east over the mountains. Soon, Kane closes her eyes and takes a short nap.
When she wakes up, she sees that Sanders has steered clear of bad weather and after an hour-long flight and a 30-minute drive from Centennial Airport, she’ll be back at her east Denver home by 7 p.m.
“They’re long days,” she says. “But there’s something a little different about the people in the Valley. They are so nice and so appreciative that we are coming to them.”