Understanding correct coding strategies is an important skill that affects billing and reimbursement for value-based cancer care. Meeting the requirements for complete and accurate documentation is critical to support healthcare claims. Both nurses and advanced practice providers have responsibilities in this work.

Molecular profiling has become essential for the treatment of metastatic colorectal cancer (CRC) when surgery cannot be considered and systemic therapy is recommended. CRC has several potential mutations that are diagnostic, prognostic, and predictive. National Comprehensive Cancer Network (NCCN) guidelines recommend that advanced practice providers conduct RAS, BRAF, HER2, and MSI testing as part of a full molecular panel, review the results, and acted on them prior to starting patients on systemic therapy.

Although cancer biosimilars have been used in European countries and in U.S. supportive care for some time, biologic medications are still new to cancer treatment in the United States. With greater support coming in at the federal level and from agencies like the U.S. Food and Drug Administration (FDA) and Federal Trade Commission, the rising biosimilar tide could soon reach a new highwater mark for healthcare professionals—and nurses specifically.

Congress returned from the winter holiday season to an administrative announcement partially curtailing flavored e-cigarettes and vaping mechanisms. Additionally, the U.S. Food and Drug Administration (FDA) began the year with the announcement of a new policy prioritizing enforcement against certain unauthorized flavored e-cigarette products to help curb the youth smoking epidemic. However, to the chagrin of the smoking cessation community, FDA is still allowing menthol and traditional tobacco flavors to be sold as usual, and reports have indicated that teens and other underage users will still opt for traditional products if they’re available.

Already the third leading cause of cancer deaths worldwide, hepatocellular carcinoma (HCC) is a continually growing burden as the incidence of obesity, type II diabetes, and hypertension also increase, which may lead to cirrhosis and nonalcoholic fatty liver disease. Its incidence is highest in Asia and Africa, where the prevalence of hepatitis B and hepatitis C may result in chronic liver disease and subsequently HCC. 

As a side effect of cancer or its treatment, anemia is associated with reduced quality of life, thanks to symptoms such as palpitations, fatigue, dyspnea, and dizziness. Etiology is often multifactorial with contributing factors such as suppression of hematopoiesis from malignancy or cancer treatments, bleeding, nutritional deficiencies, renal insufficiency, or hemolysis.

Pneumonitis is inflammation of the lung parenchyma; although rare, it can be fatal. Nishino et al. found that the overall incidence of pneumonitis with PD-1 inhibitor monotherapy was 2.7% for all-grade and 0.8% for grade 3 or higher pneumonitis. Naidoo et al. reported an approximate 5% incidence of all-grade pneumonitis, although the incidence of all-grade pneumonitis is higher with combination immunotherapy (up to 10%). The incidence is more common with higher grades in PD-1 inhibitors (versus PD-L1 inhibitors), but it occurs less often with anti-CTLA4 monoclonal antibodies. 

Because the liver is the primary site of metabolism for many drugs, baseline function testing and monitoring during cancer treatment are essential. However, the cause of an abnormal liver function test when a patient is receiving chemotherapy or immunotherapy can be difficult to determine. 

Dermatologic toxicity is the most common side effect secondary to immunotherapy. The majority of dermatologic adverse events are mild to moderate rashes on the truck of the body and upper extremities, pruritis, and vitiligo. The most common is maculopapular rash with erythematous macules, papules, and/or plaques that can sometimes be scaly; pruritis is also frequent but often underreported and undertreated and may affect quality of life.

Although immunotherapy has a unique set of toxicities compared to traditional chemotherapy, in general, grade 3 or 4 toxicities are rare—with the exception of grade 3 diarrhea and colitis. The mechanisms by which immune-related diarrhea and colitis occur are not clear. However, T-cell activation leads to high levels of CD4 T-helper cell cytokines and cytolytic CD8 T-cell tissue infiltration. Some research suggests that depleting regulatory T cells also induces autoimmunity.

Metastatic colorectal cancer (CRC) remains a significant health problem as the second leading cause of cancer death in the United States and the fourth most frequently diagnosed cancer. Despite improvements in some age groups, its incidence has actually been increasing in patients younger than 50 years. The cause of this trend is currently unknown.   

Immunotherapy may place patients at risk for distinctive toxicities that differ from traditional chemotherapy. One example is endocrine dysfunction, including hypophysitis, hypo- or hyperthyroidism, type 1 diabetes, and primary adrenal insufficiency. 

The day the administration releases the president’s budget, outlining funding levels for federal departments and their respective programs, has become an annual event around the Beltway. When that document was unveiled on March 11, 2019, it arrived on Capitol Hill like a lead zeppelin. Under the proposed budget, the National Institutes of Health’s (NIH’s) budget would see a 13% cut, and the National Cancer Institute (NCI) would have its budget reduced by 15%. The dramatic cuts in domestic spending on health, education, and welfare programs were so stark that patient advocacy and provider groups released statements individually and through coalitions to respectfully—or less so—inform decision makers that efforts will begin immediately to advocate for maintained funding levels.

Targeted therapies block the growth of cancer by interfering with specific molecules and may also be referred to as molecularly targeted drugs or precision oncology. Advanced practice RNs (APRNs) must be familiar with the various agents and their side effect profiles, including immunotherapies, hormone therapies, apoptosis inducers, monoclonal antibodies, angiogenesis inhibitors, and signal transduction inhibitors. 

Immunotherapy has a unique set of toxicities in comparison to traditional chemotherapy. Endocrine dysfunction, including hypo- or hyperthyroidism, hypophysitis, type-1 diabetes, and primary adrenal insufficiency, may occur. Advanced practice RNs (APRNs) have a role in monitoring and treating patients for endocrine-related toxicities.

Neuroendocrine cancers are rare malignancies; however, their incidence is thought to be increasing. Such tumors are characterized by their overexpression of somatostatin receptors, present in up to 80% of cases. However, a novel radiopharmaceutical may give advanced practice RNs (APRNs) a new option to treat certain gastroenteropancreatic neuroendocrine tumors.

One way that cancer has been able to evade the immune system is through overexpression of immune checkpoint proteins (immune inhibitory pathway), which allow cancer cells to be considered “self” instead of foreign and block T-cell action. Immune checkpoint proteins cytotoxic T-lymphocyte–associated 4 (CTLA-4) and programmed cell death protein (PD-1) are receptors that are expressed on the surface of cytotoxic T cells. Immune checkpoint inhibitors prevent those receptors from binding to their natural ligands, disrupting the immune inhibitory pathway. See Table 1 for a list of approved agents and indications.  

A survivorship clinic allows APRNs to practice autonomously and highlights their strengths and skills, including assessing long-term toxicities, providing expert symptom management, coordinating with other disciplines, and making referrals as appropriate. Long-term toxicities from cancer treatment are disease- and treatment-specific and will be unique to each patient.

Nurse practitioners (NPs) play an undeniably valuable role in producing quality outcomes in cancer patients. For National NP Week from November 11–17, 2018, pause with ONS to recognize, thank, and support the oncology NPs who relentlessly pursue excellence, striving for the best for their patients from diagnosis through survivorship.

The Right-to-Try law, which has been in effect since May 2018, may have a misleading name, given that it doesn’t require drug manufacturers to grant access to experimental treatments that have passed phase I trials to any patient who seeks it. Rather, the law grants terminally ill patients the “right to ask” the drug company directly, but the request can be denied for several reasons (e.g., limited supply, expense).

It takes an average of 12 years to move a drug from a new application to approval for a specific indication. Twelve years of clinical trials, documentation of several endpoints, and data surrounding incidence of observed adverse events and expected severity. Twelve years until a broader subset of patients can access the drug. 

Oral agents offer many patient benefits, one of which is the freedom to take the medication at home, allowing them to keep their daily routine and gain additional time and independence they would have spent traveling to the clinic for treatment. However, with that freedom comes additional patient responsibilities, and preparation from advanced practice RNs (APRNs) is necessary to ensure patients can self-manage symptoms and adhere to administration regimens. Research shows that patients experience severe symptoms on oral agents that may cause them to miss as many as one-third of the prescribed doses. How can APRNs empower patients to adhere to the treatment plan and ensure safe symptom self-management at home? 

As more U.S. states approve the use of medical cannabis, oncology advanced practice RNs (APRNs) may see increasing inquiries from patients who are interested in using it to manage cancer-related symptoms. However, the drug remains illegal under federal law, confounding research efforts for its use in cancer care and limiting the generation of supportive evidence.

Advancements in oncology, such as new diagnostic tools and novel therapies, have improved overall survival rates but have come at a high cost. In 2011, targeted therapies accounted for 63% of all chemotherapy expenditures. A novel cancer drug routinely costs each patient more than $100,000 per year; annual spending on cancer drugs is globally estimated around $100 billion U.S. dollars and is predicted to rise to $150 billion by 2020.

Nurse practitioners provide quality and value in radiation oncology clinics. By managing the effects of radiation during and after treatment, as well as following patients into survivorship, nurse practitioners are continually improving the quality of care that patients receive during and following treatment.

After decades of no new treatment options for advanced melanoma, several drugs for unresectable stage III and IV disease and recurrent melanoma have been approved, including newer classes of drugs such as checkpoint inhibitors (anti-PD-1 and anti-CTLA-4 drugs) and signal transduction inhibitors (BRAF, MEK, and KIT inhibitors). Advanced practice registered nurses (APRNs) must be familiar with these newer agents and classes of drugs, especially the mutations that guide their use.

Nurse practitioners (NPs) are key to improving the quality of care for their patients with cancer through advocacy—both in institutions across the country and in legislative offices on Capitol Hill. With the intent to remove barriers so NPs can help move the needle for healthcare policy, ONS’s Center for Advocacy and Health Policy held the summit, “Policy Barriers and Opportunities to NPs in Oncology,” on April 10, 2018, in Washington, DC.

As improved screening, diagnosis, and treatments lead to cancer’s classification as a chronic disease, people with cancer are surviving longer than ever before. However, with lengthened survival comes long-term physical and emotional symptoms and other sequelae that require ongoing surveillance and management. Advanced practice registered nurses (APRNs) are essential to delivering quality survivorship care.

Patients’ weight and nutrition status will often vary throughout the cancer care continuum. Weight loss might occur before the diagnosis, be one of the presenting cancer symptoms, be related to the tumor itself, or be secondary to side effects of their treatment (e.g., anorexia from chemotherapy or radiation). 

Venous thromboembolism (VTE), namely deep vein thrombosis and pulmonary embolism, is a common and serious complication. VTE is the second-leading cause of death in patients with cancer and has been connected to poorer prognoses. Other consequences include reduced short- and long-term mortality, increased risk for recurrent VTE and bleeding, a threefold increase in hospitalizations, and higher total healthcare costs. Advance practice nurses (APNs) must understand prevention strategies and treatment guidelines for this serious complication.  

With improved early detection guidelines and techniques as well as advancing cancer treatments, cancer is now a chronic disease in an already aging population. In addition, the Affordable Care Act expanded healthcare coverage to millions of previously uninsured Americans, increasing the need for medical services. With these trends in health care, nurse practitioners (NPs) are needed at the forefront to positively impact and enhance oncology care.

Recent care delivery models have focused on providing value-based care to patients. The changes provide opportunity for APNs to take a leadership role in implementing models and systems to effectively deliver that care. Here’s what APNs need to know about the new models.

Polypharmacy is the use of several medications simultaneously for different medical conditions. Data confirm that polypharmacy is prevalent in older adults with cancer, with one study reporting a minimum of four prescriptions to define polypharmacy. Many medications prescribed during cancer care are intended to treat other comorbid conditions that occur prior to a patient’s cancer diagnosis (e.g., heart disease, hypertension, hyperlipidemia, reflux disease). Reportedly, one third of individuals older than 65 years use more than one pharmacy to fill prescription medications. This can lead to further confusion for patients regarding medication management.

Promoting a culture of safety is the responsibility of all members of the healthcare team. Nurses and advanced practice providers have a unique role in ensuring patient safety, especially through interventions aimed at reducing the risk of falls and falls with injury. Hundreds of thousands of hospitalized patients fall each year, each costing organizations an average additional $14,000 and resulting in more than six additional hospital days. Up to 30% of falls result in injury, including fractures, decreased mobility, and a loss of independence.

Chimeric antigen receptor (CAR) T-cell therapy for relapsed or chemotherapy-resistant acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia, and B-cell lymphomas is becoming more common. The benefit to patients is significant: durable remission and increased comfort are two major advantages. However, severe toxicities are associated with CAR T-cell therapy that must be considered. As with any treatment modality, the best approach to management for an advanced practice oncology nurse is to fully understand those toxicities and be prepared to provide intensive supportive care.

More than a decade ago, the National Academy of Medicine first proposed that “all patients should be given a comprehensive summary and a clear explanation of the details of their cancer therapy as well as recommendations for necessary follow-up.” This seemingly simple task has proved difficult to deliver in many cancer care settings.

As an oncology clinical nurse specialist (CNS), you may find yourself answering over and over the question of, “What is it you do?” In many instances, it is a broader role then most may realize, and you wear several hats. As you explain to other oncology staff what a CNS does, focus on the three spheres of influence.

High-dose chemotherapy with hematopoietic stem cell support is a well-established treatment for many hematologic malignancies. This treatment can be a difficult journey for patients and families. Historically, patients have been treated in a traditional hospital setting in anticipation of severe side effects, including mucositis, febrile neutropenia, thrombocytopenia, and pulmonary, renal, and hepatic complications. Patients can remain profoundly immunosuppressed for months while recovering from transplant. However, better supportive care in recent years has allowed many centers to move all or a portion of their transplant care into an outpatient setting.

Venous thromboembolism (VTE) is a potentially life-threatening event characterized by clots that form in the veins, and it is the second-leading cause of death for patients diagnosed with cancer. VTE affects up to 10% of the cancer population, making it essential for oncology providers to understand the associated risk factors and preventative measures. In addition, prompt recognition and treatment for VTE becomes crucial to patient care.

Melanomas that resemble seborrheic keratosis (SK) can be challenging to diagnose correctly. SKs are often removed without being evaluated dermascopically or sent for pathologic analysis, risking the possibility of missing a diagnosis of SK-like melanoma. A new study published in JAMA Dermatology outlined the key dermascopic clues that clinicians can use to identify SK-like melanomas to prevent treatment delays and achieve the best patient outcomes.