Oncology Patient: Oncology PatientThe National Comprehensive Cancer Network (NCCN) held its 2023 annual conference in person and virtually in Orlando, FL. The meeting featured plenary sessions, interactive case review sessions on clinical issues, NCCN guideline updates, poster presentations, and an interactive exhibit hall. In his welcome message, Robert Carlson, MD, CEO of NCCN, said the meeting will help further the organization's mission to improve and facilitate high-quality, effective, equitable, and accessible cancer care so all patients can lead better lives. In a plenary session, speakers focused on recruiting and retaining staff in an era of an aging workforce, nursing shortages, and nurses considering leaving the profession. Today, there are too few nurses and physicians coming out of professional schools to offset shortages and retirements, said Timothy E. Kubal, MD, MBA, a session moderator and Infusion Center Medical Director and Medical Director of Process Excellence at Moffitt Cancer Center. The COVID-19 pandemic was “an accelerator” that exacerbated these issues, he noted, leading to burnout, overload, exhaustion, stress, and feelings of isolation. “We saw people leave the health care industry,” he noted. Now, strategies for staff retention are intentionally hardwired into management at Moffitt. Speakers said these successful retention strategies include the following: strong mentoring, especially during the first year after hiring; helping newly hired professionals map out a career ladder based on their passions; developing schedules that reflect a work/life balance; cutting back on temporary traveling nurses hired during the pandemic; adopting pathways for staff members' further education; modifying the electronic health record (EHR) to minimize “click fatigue” in documentation; and finding specific ways of publicly recognizing staff and showing appreciation for a job well done. “We're really focusing on year one,” said Rebecca L. Caires, MBA, Vice President of Operations for Oncology at Northwestern Medicine and Director of the MHA program at Northwestern University. She noted that her managers survey employees to find out how they are doing during the first year on staff, and they have created a toolkit of strategies aimed at retention. “It's relationship, relationship, relationship,” said Todd A. Pickard, MMSc, PA-C, DFAAPA, FASCO, Executive Director of Advanced Practice at the University of Texas MD Anderson Cancer Center. “The work is never enough by itself.” He noted that often when someone leaves that person is running away from someone (such as a supervisor) because he or she feels unseen and unheard. He said that most of his team includes hybrid staff (virtual and in-person), and it's all about “hearing, listening, and engaging” them to make them feel part of the solution to any workplace challenge. “We can move to wherever we're needed,” Pickard said, advising employers to take advantage of “leveraging everything [advanced practice providers] can do and not put them in a box.” He also advised modifying the EHR to help staff with documentation. “Documentation can be overwhelming...We're very aware of it,” Pickard noted. “We've customized the heck out of it.” He believes it's important to listen to clinicians and address issues with the EHR to make documentation less burdensome. “I start every meeting by recognizing someone,” said Anne H. Gross, PhD, RN, NEA-BC, FAAN, Senior Vice President for Patient Care Services and Chief Nursing Officer at Dana-Farber Cancer Institute. “You can never recognize someone enough.” She said Dana-Farber has cut back on high-priced temporary traveling nurses hired during the pandemic. She advised looking at turnover within the medical center and listening carefully to the employees' concerns. “It was sobering,” she said. “We weren't meeting the needs of our clinical assistants.” The listening sessions led to more opportunities for staff to pursue further schooling through scholarships. “Nurses have an advantage right now; no one wants to lose any nurses in an organization,” Gross said. Kubal noted that one of the areas where retention has been most critically challenged is the clinical trial infrastructure. The pandemic created a “death spiral” that speeded up employees leaving because of stress and the increased workload, said Kristi Stiffler, MPH, Vice President of Clinical Research at Fred Hutchinson Cancer Center. The organization responded by setting up a mentoring program with senior staff to boost employee retention. Also, she noted that the center started training in cohorts so that people could train together, developed electronic systems to support remote work, and embraced ways of helping staff know what they need to do to advance in their careers. Stiffler noted that most employees want more job flexibility. “We structure a hybrid approach” that involves sitting down with the employee and asking, ‘What is it that you need?’ And we can figure something out,” she shared. Staff recognition can take many forms, speakers noted. “I like to say the word ‘proud,’” Kubal said. “I say, ‘I am proud of you.’ I think people really like the word ‘proud.’ There are small things that we can always do that are actionable.” He enjoys bringing cookies for staff and giving out wine bottles with messages on them. Pickard said his team holds “mission moments” in their meetings: moments to recognize something good a staff member did that furthers the organization's mission. In a development related to the NCCN plenary session, the U.S. Senate Committee on Health, Education, Labor, and Pensions (HELP) has recognized the danger of health care workforce shortages and sought solutions to alleviate them. In response, the Community Oncology Alliance recently submitted a letter to the Senate HELP committee offering the following solutions: integrating new technology, including AI, into medical workflows; investing in workforce creation, including education, and easing barriers to workforce development; breaking up highly consolidated health care systems; and eliminating middlemen to reduce costs and delays in patient care. Immunotherapy Discussion Among the NCCN meeting's interactive sessions was one addressing the treatment of toxicities of immunotherapy in a timely manner. In this session, which used patient case studies, speakers discussed immune pneumonitis; the “three Ms” of myocarditis, myositis, and myasthenia gravis (a serious overlapping combination); and oral toxicities such as mucositis. More and more frequently, immunotherapy is being used in combination with cytotoxic therapy, so clinicians need to be alert to the fact that oral toxicities such as mucositis may be caused by the immunotherapy agent, not the cytotoxic therapy, advised John A. Thompson, MD, Medical Director of the Phase I Clinical Trials Program at Fred Hutchinson Cancer Center. As Chair of the NCCN Management of Immunotherapy-Related Toxicity Panel, he presented the case of a female immunotherapy patient with persistent mucositis and stressed that “oral toxicities may result in significant morbidity without timely intervention.” Over the past 10-12 years, there has been an explosion in the use of checkpoint inhibitors, so all clinicians will likely encounter patients with immunotherapy-related toxicities, said Marianne Davies, DNP, MSN, ACNP-BC, AOCNP, Associate Professor of Nursing at Yale University, where she is Coordinator of the Oncology Nurse Practitioner Concentration. She noted that every body system can be affected by immunotherapy, potentially causing adverse side effects. She presented the case of a man with Stage IIIA non-small cell lung cancer who developed COVID prior to the start of chemotherapy and radiation and then was treated with immunotherapy. “COVID certainly added to our challenges,” she said. The patient had worsening dyspnea, a dry cough, and palpitations, and developed immune-related pneumonitis, said Davies, a member of the NCCN Management of Immunotherapy-Related Toxicities Panel. She said the patient was treated following the NCCN guidelines. She advised clinicians to ask a patient with these symptoms about overseas travel to rule out travel-related bacterial or viral infection. The three M combination of myocarditis, myositis, and myasthenia gravis was lethal for an immunotherapy male patient with resected Stage IIIA melanoma who presented to an urgent care clinic for cold symptoms, started to decline, worsened, and ultimately died, said Jordan McPherson, PharmD, MS, BCOP, an Oncology Clinical Pharmacist in the Outpatient Solid Tumor Clinics at Huntsman Cancer Institute at the University of Utah. “This is a cautionary tale for all of us,” he said, emphasizing that someone presenting with the symptoms of this patient should have an immediate cardiac workup. Practices for LGBTQ+ Community A second plenary session at the NCCN meeting focused on best practices for addressing the needs of the LGBTQ+ community in oncology care. As previously reported by Oncology Times, the NCCN held a patient advocacy summit on the cancer care needs of the LGBTQ+ community in December 2022. Several of the speakers who participated in the NCCN patient advocacy summit also spoke at the plenary session. According to a 2021 Gallup poll, about 5.6 percent of the U.S. population self-identifies as belonging to a sexual identity gender minority. In a 2020 national survey, one-third of LGBTQ+ patients and more than 60 percent of transgender patients reported that they had experienced discrimination in health care, which can lead to delays in seeking care. “Cancer amplifies the loss of power and personal agency throughout LGBTQ life,” said Darryl Mitteldorf, LCSW, Director of Malecare, a multinational cancer survivor nonprofit and Director of the Global Prostate Cancer Alliance. Speakers at the patient advocacy summit recommended raising awareness of the needs and concerns of LGBTQ+ patients among health professionals—which the NCCN plenary session did—and incorporating information on the LGBTQ+ community into professional education from coursework through clinical training. Peggy Eastman is a contributing writer.
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