Advanced Practice Nursing (APRN)
Advanced Practice Highlights From the 2023 Tandem Meetings
In February 2023, the Tandem Transplantation and Cellular Therapy Meetings of ASTCT and CIBMTR brought the latest cutting-edge science and technologies in hematopoietic cell transplantation and cellular therapy to nurses around the globe. Here are some of the highlights I experienced as an advanced practice provider (APP) in blood and marrow stem cell transplantation.
Oncology Providers Can Transform the Trajectory of Financial Toxicity
The complexity of cancer care may affect patients’ financial toxicity more than we’ve realized. Many patients struggle with the economic burden of out-of-pocket spending for cancer care, including insurance copayments, transportation, and reduced income, as well as their psychological burden of worry and coping with less funds for food and medications. Multimodality treatments, maintenance and ongoing therapies for metastatic disease, and geographic factors such as travel for clinical trials and specialized services or paying for out-of-network care can put patients’ finances in a deeper hole. The adverse implications are significant: decreased quality of life, increased anxiety and depression, lower adherence to prescribed medications and oncology care, and reduced survival.
Oncology APRNs Are Change Agents for Tobacco Cessation
Whether by cigarette, pipe, cigar, or vaping device, tobacco use is a major risk factor for the development of many cancers; increases cancer mortality, risk of recurrence, and second primary cancers; adversely affects treatment outcomes for surgery, radiation, and chemotherapy; and affects other chronic health conditions. Initiating smoking cessation at the time of a lung cancer diagnosis improves overall survival by 30%–40%, yet 40%–50% of smokers continue to use tobacco after diagnosis.
APRNs Collaborate With PCPs on Shared Survivorship Care Models
Although they’ve conquered cancer, survivors may develop late or long-term physical, psychosocial, practical, or spiritual effects from the disease or its treatment. For example, patients with breast cancer who have completed surgery, radiation, or chemotherapy should be monitored for recurrence, lymphedema, osteoporosis, and cardiac, hormone-related, and sexual issues.
New Technology Tools Help Oncology APRNs Improve Patient Outcomes
Clinical decision support systems are tools integrated into electronic health records that include reminders for preventive care, evidence-based clinical practice guidelines, order sets, and alerts for drug prescribing. In health care, artificial intelligence converts data into knowledge to guide clinical decisions. When combined, the two technologies can guide advanced practice RNs and other providers with predictions and suggestions that go beyond human accuracy and specificity.
APRN Roles Evolve to Address Cancer Screening, Treatment Adherence, and Public Health
Responses to pandemic-related screening and treatment delays have created new opportunities for oncology advanced practice RNs (APRNs), too. In both their institutions and communities, APRNs are guiding patients and providers to reverse the increases in late cancer diagnoses, morbidity, and mortality—ultimately improving outcomes.
Boards and Committees Need Oncology APRN Voices. Will You Step Up to the Challenge?
In response to the 2010 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, the Nurses on Boards Coalition launched an initiative to increase the number of nurses in decision-making leadership capacities with a goal to place 10,000 nurses on corporate, health-related, and other panels, boards, and commissions. Yet today, we still have more work to do to advance nurses into those positions and to educate the public about nurses’ role in providing high-quality, safe patient care.
Break Bad News to Patients With This Step-by-Step Guide
When hearing results from blood work or repeat imaging—regardless of whether they are “good” or “bad”—patients want and deserve to be given information truthfully and objectively. Oncology advanced practice providers are often the bearers of bad news, which can be uncomfortable and stressful. But here’s how you can hold those conversations with finesse, empathy, and respect.
Mental Health Teams Build Programs That Prioritize Staff Well-Being
Given the inherent nature of caregiving, burnout has been part of the nursing profession since the beginning. As the complexities of the profession increase, so do nurses’ vulnerability. Oncology nurses have multiple physical, emotional, and mental demands, which, if left unaddressed, can lead to burnout, compassion fatigue, and moral distress.
Interprofessional Collaboration Helps Improve Cancer Care
Much of the care we provide is complex and requires the contributions of many knowledgeable and experienced professionals. To satisfy the National Academy of Medicine recommendations of providing safe, timely, effective, efficient, equitable, and patient-centered care, healthcare professionals must function as highly collaborative teams.
APRN Leaders Mentor Students to Tackle Clinical Practice Issues
Nursing is among the top careers for job growth, with an estimated 7% increase in the nursing workforce by 2029. As new students train to enter or advance in the profession, advanced practice RNs (APRNs) must mentor and empower them to integrate evidence-based practice (EBP) into their care.
Diagnose and Treat Hypercalcemia of Malignancy
Hypercalcemia of malignancy (HCM) is a common paraneoplastic syndrome associated with poor prognosis that affects approximately 20%–30% of patients with cancer. It’s most often seen in patients with breast, lung, renal, or ovarian cancers; squamous cell carcinoma of the head and neck; multiple myeloma; and certain lymphomas.
APRNs Are Essential in Survivorship Programs
As the number of cancer survivors continues to grow in the United States, so too does the need for cancer survivorship programs. Oncology advanced practice RNs (APRNs) are essential team members as institutions develop and deliver comprehensive and holistic programs to meet survivors’ needs.
Targeted Therapies Are Transforming the Treatment of Non-Small Cell Lung Cancer
Testing for molecular biomarkers has become a mainstay in determining treatment approaches for advanced-stage non-small cell lung cancer. Typically, next-generation sequencing identifies any potential genomic variants that are associated with oncogenic driver events and can be targeted with oral tyrosine kinase inhibitors.
An APRN’s Clinical Guide to Medical Marijuana
More and more patients with cancer are asking their healthcare providers whether medical marijuana can help them manage symptoms and side effects. Advanced practice RNs (APRNs) must be prepared to educate patients and assess their eligibility for therapeutic cannabis.
Guidelines Help APRNs Navigate the Law and the Science for Medical Marijuana
Research and regulations regarding medical marijuana are constantly evolving. Advanced practice RNs (APRNs) caring for patients who may use cannabis need a knowledge base and guidance for practice. During her session on April 29, 2021, for the 46th Annual ONS Congress™, Kathleen Russell, JD, MN, RN, associate director of nursing regulation at the National Council of State Boards of Nursing (NCSBN), reviewed key points from NCSBN’s Guidelines for the Nursing Care of Patients Using Marijuana that are particularly relevant to oncology APRNs.
Here’s Why Advanced Practice Nurses Are Ideally Suited to Manage Telehealth Programs
As use of digital health or telehealth has grown, healthcare providers have had to address challenges and get buy-in on multiple levels. Will patients feel comfortable and heard during a phone call or video chat? Will staff still be able to provide optimal care? Advanced practice RNs can apply their skills and experience to create a supportive telehealth environment for patients and families as well as for professional staff.
As New Roles Emerge, APRNs Have More Opportunities in Cancer Care Than Ever Before
Oncology advanced practice RN (APRNs) are in an ideal position to put their leadership, clinical practice, critical thinking, and organization management expertise to use in new ways to advance and add value to cancer care. During her April 20, 2021, session at the 46th Annual ONS Congress™, Rosanne Casal, DNP, APN-BC, AOCNP®, from University Hospitals Seidman Cancer Center in Cleveland, OH, shared three examples: benign hematology, ambulatory acute care, and bone marrow biopsy.
Onboarding and Supporting New Providers Are Your Responsibilities as an APRN Leader
Contributing to the orientation and onboarding of new advanced practice RN (APRN) providers supports optimal patient outcomes, professional satisfaction, and nurse retention. Orientation involves working through the hospital’s training program, policies and procedures, organizational structures, and mission or vision statements, whereas onboarding builds engagement and relationships in the organization over many weeks to months. Some institutions have formalized, detailed processes for orientation and onboarding, but others may offer very little structure and support.
Management Strategies for Cutaneous Toxicity From EGFR Inhibitors
Epidermal growth factor receptor (EGFR)-targeted therapy is effective for several solid tumor malignancies, primarily non-small cell lung cancer with EGFR mutation and metastatic colorectal cancer. Although the agents spare patients from typical side effects seen with more conventional cytotoxic chemotherapies, such as nausea or vomiting, they do have a unique side-effect profile, including potentially dose-limiting cutaneous toxicity.
Billing and Coding Breakdown Helps Nurses Recognize the Realities of Reimbursement
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.
Advanced Practice Nurses Are at the Heart of Patient Care in Cardio-Oncology
Cardiovascular disease and cancer, the two leading causes of mortality worldwide, share risk factors that have a direct impact on patient care and survival. During a session for the inaugural ONS Bridge™ virtual conference, Anecita P. Fadol, PhD, APRN, FAANP, FAAN, of the University of Texas MD Anderson Cancer Center, discussed what advanced practice nurses need to know about the evolving specialty of cardio-oncology to improve patient outcomes.
Advanced Practice Providers Serve a New Role in Radiation Oncology
No matter the subspecialty, advanced practice RNs have a significant role in patient treatment and care, but little data exist about their role in radiation oncology. During a presentation at the inaugural ONS Bridge virtual conference, Lorraine Drapek, DNP, FNP-BC, AOCNP®, of Massachusetts General Hospital, and Katie Bukolt, MSN, APRN, NP-C, AOCNP®, of Baylor Charles A. Sammons Cancer Center, discussed the nuances of advanced practice in radiation therapy settings.
BRAF Mutations Guide Treatment in Metastatic Colorectal Cancer
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.
Nurses Will Forge New Territory With Biosimilars in Cancer Care
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.
FDA Vaping Regulations; CMS Scope of Practice; APPs Improve Health Care
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.
Newer Therapies at Last Offer Systemic Options for Metastatic HCC
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.
Manage Cancer-Associated Anemia With Erythropoietin-Stimulating Agents
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 With Immunotherapy Treatment
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.
To Prevent Hepatoxicity, Monitor Liver Function During Cancer Treatment
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.
Diagnose and Manage Dermatologic Toxicity Secondary to Immunotherapy
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.
Manage Immunotherapy-Related Diarrhea and Colitis
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.
Stay Up to Date on Clinical Treatments for Metastatic CRC
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.
How APRNs Can Manage Immunotherapy-Related Hypophysitis in Patients With Cancer
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.
Prompt APRN Recognition of Oncologic Emergencies Can Improve Outcomes
Infusion reactions, hypersensitivity reactions, anaphylaxis, and tumor lysis syndrome are oncologic emergencies that are seen in both inpatient and ambulatory settings. Advanced practice RNs (APRNs) are often the first providers to respond to those emergencies. During a session on Friday, April 12, 2019, at the ONS 44th Annual Congress in Anaheim, CA, Patricia Jakel, RN, MN, AOCN®, of the University of California, Los Angeles, Health System in Santa Monica, discussed oncologic emergencies and the APRN’s role in rapid identification of a diagnosis.
Possible NIH Cuts; Sharpless FDA Commissioner; NPs on the Rise
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.
What Is the APRN’s Role in Managing Patients Receiving Targeted Therapy?
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.
How APRNs Can Manage Immunotherapy-Related Hypothyroidism in Patients With Cancer
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.
The Role of the APRN in Monitoring Patients Receiving Peptide Receptor Radionuclide Therapy
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.
Take a Closer Look at Immune Checkpoint Inhibitors
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.
Hematology Training Is Suboptimal for APPs
Advanced practice providers (APPs) may have limited subspecialty training options for hematology, and postgraduate fellowships focused on education in both malignant and nonmalignant hematologic disorders appear to be lacking for APPs. Yi L. Hwa, DNP, of the division of hematology at the Mayo Clinic in Rochester, MN, discussed the findings of a research team’s web-based needs assessment survey that found significant gaps in subspecialty hematology training for APPs at the ASH Annual Meeting on December 1, 2018.
APRN-Led Clinics Enable Comprehensive Survivorship Care
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.
This Week, Recognize and Thank Your Oncology Nurse Practitioner Colleagues
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.
Educational Approach Improves Oncology Advanced Providers’ Knowledge and Experience With Immunotherapy
As more immunotherapies come to market, advanced practitioners need to know how to prescribe and recognize, triage, and manage immune-related adverse events (irAEs) as well as champion education about the agents’ benefits and risks.
An APP-Led Infusion Center Can Reduce Hospital Use for Patients With Cancer
Emergency department visits by patients with cancer can be unnecessary, costly, and potentially dangerous. Most symptom management concerns can be safely and quickly handled in the outpatient setting, but provider access can be a barrier.
What APRNs Need to Know About Right to Try
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).
How Advanced Practice Nurses Can Recognize It; Report It in an Era of Fast-Track Drug Approvals
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.
How APRNs Can Support Patients During Oral Agent Treatment
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?
APRNs Must Stay Educated About Medical Cannabis in Cancer Care
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.
APNs Give Practical Advice for Establishing Clinics and Implementing Programs
Advanced practice nurses (APNs) are creating new and innovative programs that educate patients and help them live better, healthier lives. Lorraine Drapek, DNP, FNP-BC, AOCNP®, Geline Joy Tamayo, MSN, RN, ACNS-BC, OCN®, TTS, Suzanne McGettigan, MSN, CRNP, AOCN®, ANP-BC, and Edward Bentlyewski, MSN, APN, NP-C, AOCNP®, discussed their experiences with APN-run clinics and program implementation during a session at the 43rd Annual Congress in Washington, DC.