Oncology Advanced Practitioners Research Articles

Maintaining Survival While Improving Quality of Life: An Advanced Practitioner–Led Pilot Feasibility Study to Reduce Radiation Dose in Children With Brain Tumors

Purpose: Oncology advanced practitioners (APs) are on the front line in treating adverse effects. Among children with brain tumors, treatments such as craniospinal irradiation (CSI) cause neurocognitive injury, endocrinopathies, and ototoxicity. High-dose CSI with concurrent chemotherapy allows high-risk embryonal tumors (non-anaplastic) good survival (70%), but significant distressing effects are commonly treated by APs in multidisciplinary long-term follow-up. The aim of this study was to test feasibility of reducing radiation dose with an AP-led protocol. Methods: An interdisciplinary team developed this pilot study with the primary outcome of fewer than two deaths in 10 patients (80% survival). Secondary outcomes were feasibility of an AP-led treatment protocol and acute/late effects of treatment. The AP held a pioneering role as principal investigator of a tumor treatment study. Exclusion criteria included age less than 3 years and anaplasia. The CSI was reduced from 36 to 24 Gy. All other treatment was standard. Results: Survival rate exceeded the primary outcome threshold (88%); the accrual rate (80%) and follow-up neurocognitive testing rate (75%) were acceptable. Eight children ages 3 to 19 years (M = 8) with tumors of varied molecular subtyping were enrolled. The single death occurred 2.5 years from diagnosis of multiorgan failure (without evidence of tumor). The mean survival is 11 years, with two college and one graduate degrees. Acute and late effects were decreased compared with the higher-dose CSI. Conclusion: APs who treat cancer adverse effects can also conduct clinical prospective studies to maintain survival rates and improve quality-of life-outcomes.

Advanced Practitioners in Hematology and Oncology: A Call to Action

The hematology and oncology field is experiencing a wave of challenges in the form of workforce shortages, increasing complexity of care, and a growing population of cancer survivors. These factors all contribute to pressure on oncology practices to improve efficiency. Advanced practitioners (APs) in hematology and oncology have become integral members of the interdisciplinary team. They represent a specialty workforce critical to the delivery of timely, quality, expert cancer care across a broad range of services. With the growth in the AP profession in terms of numbers and services provided, it is critical for AP organizations and leaders to accurately measure AP contributions to care, describe fair compensation for AP services, deploy strategies to assess and reduce burnout among APs, and support continuous process improvement. This series of articles in the Journal of the Advanced Practitioner in Oncology provides data describing the growing role of the AP along with recommendations to further advance the profession and improve patient care.

Advanced Practitioners in Hematology and Oncology: State of the Workforce

Advanced practitioners (APs), including nurse practitioners (NP), physician assistants (PA), pharmacists, and nurses with advanced degrees, including advanced practice registered nurses (APRNs), play a critical role in quality, timely, and expert cancer care. Burnout, retention, and resilience have been studied in physician groups. However, there is a paucity of data specific to APs in hematology and oncology. The Advanced Practitioner Society for Hematology and Oncology (APSHO) conducted an online survey that used validated tools to measure burnout and work-life balance among APs who are members of APSHO. Among the 366 respondents completing all items of the Maslach Burnout Inventory (MBI) and the Areas of Worklife Survey (AWS), participants felt engaged (34.2%) but overextended (37.4%) and reported burnout (17.8%). These results indicate a need to evaluate workloads, improve communication, and deploy strategies for support and advocacy to improve work-life balance within this group. The stability of the AP workforce is essential to excellence in patient care, provider resilience, and cancer outcomes. Creating a culture of open communication and strong AP leadership with data streams and metrics specific to the hematology and oncology workforce will help to inform health systems, consumers of health care, professional societies, educational institutions, and APs. Systematic and regular assessment of burnout and barriers to work-life balance for APs is essential to sustained adaptation of strategies to reduce burnout and retain APs.

Understanding Advanced Practitioner Prescriptive Privileges for Anticancer Therapies: A National Survey

Oncology advanced practitioners (APs) work in collaboration with physicians to provide high-quality, specialized oncology care. Data are lacking on individual AP function within different practice settings, specifically around the prescribing of anticancer therapies. Our primary aim was to conduct a prospective, national, web-based survey to understand AP roles in prescribing anticancer therapies and the related privileging process(es) in both academic and community oncology practice settings. A 38-question survey was developed based on a review of published oncology AP data sets, expert input, and cognitive interviews with key AP informants. Survey domains included basic respondent demographics, practice setting information, and prescribing and privileging practices. The survey was distributed by the Association of Community Cancer Centers (ACCC) and the Advanced Practitioner Society for Hematology and Oncology (APSHO) in late 2022. 180 individuals responded, and 135 oncology APs completed the survey. The majority of respondents practice in states that allow prescriptive privileging for anticancer therapies. Only half of those that have prescriptive privileging have an established privileging and competency process at their practice setting. Among the nurse practitioners and physician assistants practicing in primarily independent roles, only about half can prescribe both standard-of-care and investigational therapies. This national survey provides valuable insights into the prescribing practices of oncology APs. The findings highlight the need to further develop standardized privileging and competency strategies within the AP community. By addressing these gaps, APs can play a crucial role in addressing workforce shortages in oncology and optimizing patient outcomes.

The Value of the Advanced Practitioner in Hematology and Oncology: Establishing Benchmarks

Advanced practitioners (APs) in hematology and oncology (heme/onc) practice and provide oversight across myriad settings, including outpatient, inpatient, specialty centers, infusion centers, and other care settings. Understanding the complexity of care within the specific role APs play in providing day-to-day services across the oncology service line and throughout the continuum of care is critical to developing productivity metrics that adequately reflect the value and scope of the heme/onc AP role. Productivity metrics specific to APs are lacking. Physician models, commonly applied to APs, do not adequately reflect the changing landscape of oncology services, and more importantly do not capture nonbillable services APs provide that are essential to run a practice safely, effectively, and efficiently. Here we describe results of the APSHO Productivity, Burnout, and Work-Life Balance Survey deployed to APSHO members in October 2022 with insight into the day-to-day workload of heme/onc APs, levels of burnout, and perceptions of work-life balance in their current role. Results of the survey confirm the significant amount of time APs spend performing tasks that are not billable but are crucial for access to care and treatment, patient safety, practice efficiency, and downstream revenue. Imperative to an agile and stable heme/onc workforce is an AP leadership structure. Advanced practitioner leaders are at the cornerstone of AP retention, yet metrics for measuring AP leader productivity are also lacking. Now, more than ever, it is essential to accurately describe and assign value to the broad scope of services APs and AP leaders bring to heme/onc practices.

Rethinking Medical Aid in Dying: What Does It Mean to 'Do No Harm?'

Medical aid in dying is the act of prescribing lethal medications to a consenting patient who can self-ingest them with the intent of hastening their death. A majority of patients who utilize medical aid in dying are patients with terminal cancer. As oncology patients continue to choose deaths most suitable to them, it is critical that advanced practitioners in oncology be knowledgeable regarding this end-of-life decision. With 40 states denying patients access to medical aid in dying, the purpose of this end-of-life care review is not to persuade for or against medical aid in dying, active euthanasia, or other forms of dying with dignity, but rather to shed light on patient decisions and available end-of-life options for patients where medical aid in dying is not honored. One author has succinctly named this era as "Dying in the Age of Choice," and therefore the purpose of this article is to present the current state of medical aid in dying. The article presents case studies for the reader, as well as a comparison of California's statistics with the national average. Much like other controversial subjects that intersect morality, religion, and Hippocratic medical ethics, practitioners in the healing arts must remain unbiased and honor the wishes of patients even when they differ from their own. In serving the population with the highest utilization of medical aid in dying, advanced practitioners in oncology should be familiar with the legal specifications in their state or be abreast of solutions for guiding patients through end of life in the states where medical aid in dying remains illegal.

Barriers to Adherence to Cancer Treatments Among Head and Neck Cancer Patients.

Head and neck cancer patients often undergo a demanding treatment schedule requiring radiation and chemotherapy. Adherence to these treatment schedules is affected by several issues, including socioeconomic factors, characteristics of the disease and treatment plan, symptoms, and side effects. Oncology advanced practitioners (APs) work directly with patients with head and neck cancer (HNC) during active treatment, often screening for and managing side effects and providing referrals. Evidence-based interventions and innovative strategies for the oncology AP to improve HNC patients' quality of life and treatment adherence include frequent distress screening, AP-led educational interventions and symptom management clinics, and incorporating technology to allow for close contact with patients during treatment.

A Call to Action: The Role of the Oncology AP in Equitable Cancer Care.

The COVID-19 pandemic has only further brought to light how racism, bias, and lack of equity can result in social injustice, morbidity, and mortality. A panel of four advanced practitioners convened at JADPRO Live Virtual 2021 to examine oncology advanced practitioners’ capacity for enhancing equitable cancer care in the domains of care coordination and communication, clinical trials, and acknowledging and mitigating bias.

Role of Oncology Advanced Practitioners to Enhance Clinical Research.

Background:Oncology advanced practitioners (APs), including nurse practitioners, clinical nurse specialists, physician assistants, and clinical pharmacists contribute significantly to quality cancer care. Advanced practitioners enhance value across the spectrum of cancer care. Research is an underdeveloped component of quality care, as well as an underdeveloped component of AP practice. Understanding research-related attitudes and roles of APs could lead to enhanced clinical trial accrual, conduct, and protocol development.Methods:A nationwide survey addressing attitudes, beliefs, and roles of APs regarding clinical research was distributed by the Association of Community Cancer Centers (ACCC) and Harborside in early 2020.Results:408 oncology APs completed the survey. Thirty-five percent practice in an academic setting and 62% in the community. Nearly all respondents believe clinical trials are important to improve care, and over 90% report clinical trials are available at their practice. About 80% report being comfortable discussing the topic of clinical trials with patients and are involved in the care of trial participants. Sixty percent are comfortable discussing available trials, and 38% routinely explore available trials with patients. While 70% report approaching eligible patients about trials, only 20% report doing so “a great deal” or “a lot.” Ninety percent report that APs should play a role in clinical research, and 73% want to be more involved. Barriers identified to greater AP clinical trial involvement include lack of time, inadequate awareness of trial specifics, and a lack of a formal role in protocol development and leadership.Conclusions:Advanced practitioners are engaged and interested in clinical trials and believe clinical research is important to improve cancer care. Multidisciplinary team integration, trials-related education, and policy change are needed to employ APs to their full potential within cancer clinical trials.

T-Cell Lymphomas: Online Education Significantly Improves Clinicians' Knowledge of Therapeutic Advances

Background: Therapeutic advances have made the treatment of T-cell lymphomas (TCLs) more effective, less toxic, and more individualized, but research indicates that the multidisciplinary team faces challenges in maintaining a working knowledge of evolving data that can inform clinical decision making. This study was conducted to determine if an online, case-based continuing medical education (CME)/nursing continuing professional development (NCPD) activity could improve clinicians' skills regarding the individualized treatment of patients with TCLs. The educational intervention was intended for all members of the multidisciplinary team: hematologist-oncologists, oncology advanced practitioners and nurses, and other health care professionals involved in the treatment of patients with TCLs.Methods: The CME/NCPD-approved live webinar series titled Update on Therapeutic Advances in T-Cell Lymphoma was presented on March 11, 2021 and March 15, 2021, and was made accessible as a CME/NCPD-approved enduring webinar archive starting on March 18, 2021. Learners participated in a 1-hour online activity regarding current challenges and emerging opportunities in the management of newly diagnosed and relapsed/refractory TCLs. The presentation highlighted mechanisms of action, efficacy, and tolerability of newer therapeutic agents, along with adverse event management strategies. Learners engaged in active learning during case studies that explored patient and disease characteristics that inform care, risk stratification, and treatment.Prior to the activity and following its completion, learners were given a repeated pairs pre- and post-activity assessment consisting of case-based questions that gauged their ability to apply emerging data and guideline recommendations to clinical decision making. Each learner served as their own control. The percentages of learners obtaining correct responses on the pre-activity assessment were compared to those on the post-activity assessment using a chi-squared test. Additionally, learners completed an evaluation of the educational content and self-reported the influence that they judged the activity would have on their future practice.Results: As of July 29, 2021, 218 clinicians had completed the activity for credit. Online education had a significant impact on gains in knowledge and competence in the selection of personalized treatment for patients with TCLs (Figure 1). Learners demonstrated substantial improvements in knowledge of the superior efficacy of mogamulizumab versus vorinostat for a patient with previously treated stage IVB mycosis fungoides (55.67% mean improvement on the post-activity assessment, P < .000001); of the association of the TET2 mutation with angioimmunoblastic T-cell lymphoma (AITL) (54.35% improvement, P < .000001); of the predicted efficacy of oral azacitidine/CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) for an older patient with peripheral T-cell lymphoma-T follicular helper (PTCL-TFH) (31.28% improvement, P < .000001); of the appropriateness of granulocyte colony-stimulating factor (G-CSF) prophylaxis for a patient with CD30-positive PTCL commencing treatment with brentuximab vedotin/CHP (cyclophosphamide/doxorubicin/prednisone) (19.90% improvement, P < .000001); and of the superior efficacy of brentuximab vedotin versus methotrexate for CD30-positive primary cutaneous anaplastic large cell lymphoma (pcALCL) (17.33% improvement, P < .000001). The case-based assessment questions and answer choices can be seen in Table 1. Learners' responses on the activity evaluation can be seen in Figures 2 and 3.Conclusions: These data indicate that online, case-based CME/NCPD-approved activities can result in statistically significant improvements in clinicians' knowledge of therapeutic advances and can increase their sense of competence and confidence in personalizing treatment plans and managing treatment-related adverse events for patients with TCLs.Acknowledgements: This activity was supported by independent educational grants from Kyowa Kirin and Seagen. [Display omitted] DisclosuresHorwitz: Affimed: Research Funding; Aileron: Research Funding; ADC Therapeutics, Affimed, Aileron, Celgene, Daiichi Sankyo, Forty Seven, Inc., Kyowa Hakko Kirin, Millennium /Takeda, Seattle Genetics, Trillium Therapeutics, and Verastem/SecuraBio.: Consultancy, Research Funding; Acrotech Biopharma, Affimed, ADC Therapeutics, Astex, Merck, Portola Pharma, C4 Therapeutics, Celgene, Janssen, Kura Oncology, Kyowa Hakko Kirin, Myeloid Therapeutics, ONO Pharmaceuticals, Seattle Genetics, Shoreline Biosciences, Inc, Takeda, Trillium Th: Consultancy; Celgene: Research Funding; C4 Therapeutics: Consultancy; Crispr Therapeutics: Research Funding; Daiichi Sankyo: Research Funding; Forty Seven, Inc.: Research Funding; Kura Oncology: Consultancy; Kyowa Hakko Kirin: Consultancy, Research Funding; Millennium/Takeda: Research Funding; Myeloid Therapeutics: Consultancy; ONO Pharmaceuticals: Consultancy; Seattle Genetics: Consultancy, Research Funding; Secura Bio: Consultancy; Shoreline Biosciences, Inc.: Consultancy; Takeda: Consultancy; Trillium Therapeutics: Consultancy, Research Funding; Tubulis: Consultancy; Verastem/Securabio: Research Funding.

Summit Explores Role of Oncology Advanced Practitioners in Equitable Cancer Care Delivery

Summit Explores Role of Oncology Advanced Practitioners in Equitable Cancer Care Delivery

Improving Health Equity: The Role of the Oncology Advanced Practitioner in Managing Implicit Bias.

Implicit bias (IB) is the involuntary activation of thoughts, feelings, attitudes, or stereotypes that exist outside of conscious awareness. Implicit bias develops early in life and research documents the existence of IB across health-care settings. Negative IB impacts patient-provider interactions, produces inferior patient outcomes, and contributes to health-care disparities. Oncology APs are subject to IB and should be aware of its potential impact on professional practice. This manuscript explores the concept of IB and reviews evidence examining the clinical impact of IB in the oncology setting. Strategies for identifying and mitigating IB are explored. Highlights include the use of the Implicit Association Test and emotional intelligence. Advanced practice implications are discussed and range from self-improvement to organizational transformation.

Needs Assessment for an Introductory Radiation Oncology Curriculum for Advanced Practice Providers

Advanced practice providers (APPs) are increasingly integral in clinical care models1. Limited didactic or clinical experience exists for APPs in radiation oncology (RO). 1 Bruinooge SS Pickard TA Vogel W et al. Understanding the Role of Advanced Practice Providers in Oncology in the United States. J Oncol Pract. 2018; 14: e518-e532 Crossref PubMed Scopus (19) Google Scholar ,2 Martin KL Krechmer B Boyajian RN Reynolds MC Cagney DN Martin N. Advanced Practice Providers in Radiation Oncology. Pract Radiat Oncol. 2019; Google Scholar Despite 80% of their role dedicated to patient care, 1 Bruinooge SS Pickard TA Vogel W et al. Understanding the Role of Advanced Practice Providers in Oncology in the United States. J Oncol Pract. 2018; 14: e518-e532 Crossref PubMed Scopus (19) Google Scholar ,2 Martin KL Krechmer B Boyajian RN Reynolds MC Cagney DN Martin N. Advanced Practice Providers in Radiation Oncology. Pract Radiat Oncol. 2019; Google Scholar there is currently no dedicated curriculum for RO APPs. Training has followed an "on the job" model that relies on the established team (physicians, APPs, and nurses) to educate new APPs, resulting in increased times for APPs to achieve clinical independence. 3 WH V Advanced Practitioners in Oncology: Meeting the Challenges. Journal of the Advanced Practitioner in Oncology. 2010; 1: 13-18 Google Scholar ,4 Nevidjon B Rieger P Miller Murphy C Rosenzweig MQ McCorkle MR Baileys K Filling the gap: development of the oncology nurse practitioner workforce. J Oncol Pract. 2010; 6: 2-6 Crossref PubMed Scopus (33) Google Scholar Training also varies in content and quality and may inadequately cover foundational RO topics. Without a dedicated focus on core RO principles, APPs may lack a deep understanding of treatments and be unable to communicate clearly and effectively with colleagues and patients. We sought to address these concerns by performing a needs assessment to guide APP curricular development. This study aimed to measure current post-graduate RO training provided to practicing APPs across the United States via an anonymous survey.

Addiction in Patients With Cancer: Challenges and Opportunities.

Addiction is complex and multifactorial. Recognition provides the opportunity to provide potentially life-saving treatment. Oncology patients are not excluded from substance use disorders (SUDs) and the opioid epidemic. Patients with current or past SUDs may develop cancer, and an SUD may also develop during cancer treatment. Therefore, this unique subset of patients potentially has two fatal diseases: cancer and an SUD. Most oncology advanced practitioners (APs) are unprepared to care for SUDs in patients with cancer. Pain is one of the most common symptoms in the cancer population, and cancer-related pain is often treated with opioids. Opioid exposure increases the risk of developing an opioid use disorder (OUD). In addition, a cancer diagnosis can have a significant impact on mental health and wellness, and patients may use substances to cope with psychological distress. Drug and alcohol use exists on a continuum and while not all use is problematic, it may have adverse consequences. A cancer diagnosis provides another possibility for patients to engage in services and treatment for their unsafe use and/or addiction. The case study in this article of a patient with cancer and an SUD is an example of the challenges associated with the chronic and relapsing nature of addiction. Oncology advanced practitioners have the opportunity to positively influence outcomes through the assessment of substance use and adoption of harm reduction techniques in all patients with cancer.

On Becoming an Ally

Earlier this year, I was asked to participate in a meeting titled “Virtual Summit to Define the Role of Oncology Advanced Practitioners in Equitable Cancer Care Delivery: A Closer Look at Care Coordination, Clinical Trials, and Implicit Bias” held by the Association of Community Cancer Centers (ACCC) and Harborside. This conversation brought together a diverse group of participants to discuss the unique difficulties that people of color and underrepresented populations face with a cancer diagnosis and potential pathways for improvement.

Treatment Options for Germline BRCA-Mutated Metastatic Pancreatic Adenocarcinoma.

Pancreatic cancer is the fourth leading cause of death from cancer in both men and women. Pancreatic cancer is typically diagnosed at an advanced stage and has an overall 5-year survival of approximately 9.3%. The National Comprehensive Cancer Network recommends both germline testing (testing cells such as blood or skin that do not have cancer) as well as somatic testing (testing cells with cancer) for pathogenic variants that may increase the risk of pancreatic cancer. In December 2019, the U.S. Food & Drug Administration approved the poly(ADP-ribose) polymerase (PARP) inhibitor olaparib for maintenance treatment of germline BRCA-mutated metastatic pancreatic adenocarcinoma in individuals who have completed at least 16 weeks of progression-free treatment with first-line platinum-based chemotherapy. This new therapy option has implications not only for treatment but also for the role of the oncology advanced practitioner as genetic testing becomes more prevalent in the care of patients with cancer.

Understanding Attitudes and Roles of Oncology Advanced Practitioners in the Setting of Cancer Clinical Trials: A Pilot Study.

PurposeOncology advanced practitioners (APs), including nurse practitioners, physician assistants, clinical nurse specialists, and pharmacists, are skilled health-care providers who contribute significantly to quality cancer care. However, little is known about how APs function within the clinical trials arena. With low rates of clinical trial enrollment among the adult oncology patient population, APs could play an important role in improving clinical trial enrollment.MethodsA descriptive cross-sectional study was conducted based on a 57-item survey of oncology APs' attitudes, beliefs, and roles in relation to cancer clinical trials.ResultsTo assess validity and internal consistency of the survey, a pilot data collection was completed on 14 respondents from Hawaii. The survey's internal consistency across the subscales was moderate to very high, with Cronbach's alpha ranging between 0.55 and 0.86. The majority of oncology APs were interested in being more involved in the clinical trials process, and many are registered as investigators through the National Cancer Institute (NCI). However, few respondents reported being involved in recruitment, consenting, protocol development, or being actively involved with a research base.ConclusionsThis survey was found to be a valid tool to measure APs' attitudes and roles in regards to clinical trials. This survey is just the beginning of data collection in regards to clinical trials among this group of health-care professionals.RecommendationsTo gain further insight into oncology APs and their roles in clinical trials, it is recommended that this survey be implemented on a national level as a first step in moving this issue forward.

Practical Considerations for Integrating Biosimilars Into Clinical Practice.

The development of innovator biologics and now their biosimilars has created some unique challenges in oncology practice. The oncology advanced practitioner (OAP) must understand the key differences between the innovator biologic and biosimilars in regard to efficacy, safety, and immunogenicity. In addition, the OAP must be able to evaluate and successfully navigate factors that may affect the adoption of biosimilars, such as the perceived cost-benefit and clinician and patient acceptance.

Are Current Metrics Adequate to Demonstrate the Value of Oncology Advanced Practitioners?

At JADPRO Live Virtual 2020, Jason Astrin, DMSc, MBA, PA-C, DFAAPA, defined the concepts of productivity and value and discussed strategies for measuring the value of oncology advanced practitioners in order to recognize advanced practitioner contributions to quality care and provide meaningful incentives.

Integration of Palliative Care in the Role of the Oncology Advanced Practice Nurse

Numerous organizations have cited the increasing demand for palliative care in oncology and the challenge of a limited workforce to deliver specialty palliative care. Advanced practitioners in oncology can provide generalist or primary palliative care to complement the care provided by specialists and enhance the overall provision of care. This article reports on a National Cancer Institute–funded training program to prepare advanced practice nurses to incorporate palliative care within their practice. One-year follow-up of the first three national cohorts (N = 276) included evaluation of goal achievement as these nurses integrated palliative care within their oncology practice. Goal analysis reported here demonstrates the success of the training program in impacting practice as well as the barriers to implementation efforts. The advanced practice registered nurses' implemented goals included extensive training of clinicians across disciplines and numerous systems changes to improve delivery of palliative care. Advanced practice nurses will continue to be a valuable source of extending palliative care into oncology care to support patients and families across the disease trajectory.