Expanding the role of advanced practice providers (APPs) in cancer clinical trials

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Background: Advanced Practice Providers (APPs) represent a growing and increasingly important component of the oncology workforce. However, APP roles in clinical research are not clearly understood, and certain policies may limit participation. For instance, National Cancer Institute (NCI) Cancer Therapy Evaluation Program (CTEP) historically prohibited APPs from signing orders on CTEP-sponsored studies, even at centers where APPs have antineoplastic privileges allowing them to order cancer treatments as standard therapy or on non-CTEP studies. At the UT Southwestern Harold C. Simmons Comprehensive Cancer Center (SCCC), more than 100 active CTEP-sponsored trials account for approximately 30% of therapeutic enrollment. Given these considerations, we approached CTEP regarding potential policy change. Methods: In early 2020, we raised the issue of disparities in allowed APP delegation between (1) CTEP trials and (2) standard practice and non-CTEP trials to NCI/CTEP leadership. Later that year, CTEP organized a discussion on the topic with SCCC representatives and other stakeholders. Subsequently, NCI deployed a survey to National Clinical Trials Network (NCTN) and Experimental Therapeutics Clinical Trials Network (ETCTN) centers asking about the role of APPs at their respective institutions. Results: Following the survey, CTEP revised its policy, allowing appropriately credentialed APPs to sign treatment orders on CTEP-sponsored trials, effective September 1, 2021. After completing required regulatory steps to update trial protocols at UTSW SCCC, approved APPs began signing cancer clinical trial treatment orders in January 2022. Since that time, the proportion of trial treatment orders signed by APPs at SCCC has increased from 1% in January 2022 to 20% in May 2022. Conclusions: The role of APPs in cancer care can be further enhanced by alleviating barriers and allowing providers to perform at the full scope of practice, thereby further integrating care teams critical to compliant and safe clinical trial participation.

Development of evidence-based clinical pathways for an outpatient oncology acute care clinic

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Background: Oncology patients frequently experience acute physical symptoms related to cancer and its treatment. Management of symptoms is best accomplished using evidence-based clinical care. When implementing an advanced practice provider (APP)-led oncology acute care clinic, evidence-based clinical pathways were developed to ensure standardization among treating providers. Methods: The top ten emergency department admitting diagnoses for oncology patients identified by the Centers for Medicare and Medicaid Services provided the foundation for development of the clinical pathways. Relevant primary literature, National Comprehensive Cancer Center Network guidelines, and American Society of Clinical Oncology guidelines were reviewed for development of outpatient oncology acute care clinical pathways. The information was cross-referenced with institutional data to confirm applicability to the patient population. A multidisciplinary team including nursing, pharmacy, laboratory services, radiology, information technology, and administrative staff reviewed the workflow to ensure best processes. The pathways were reviewed by oncologists, APPs and pharmacists before finalization. Results: Nine evidence-based clinical pathways were developed by August 1, 2020. From August to December 2020, 165 patient visits took place in the outpatient oncology acute care clinic. Gastrointestinal manifestations (25%), hypovolemia/weakness (25%), and infections (17%) were the most frequently encountered symptoms. Evidence-based clinical pathways were followed for patients with a chief complaint with an associated algorithm (N=124). Conclusions: Implementation of clinical pathways facilitate best practice standardization when ordering labs, tests, and medications while enhancing the acceptance of the new service. The pathways will be reviewed and updated by a multidisciplinary team every 3 months to ensure current evidence-based practices. Semi-annual pathway audits have been implemented to evaluate utilization and optimize patient outcomes, as well as determine areas of improvement and growth. Areas of opportunity identified during the first pathway audit included creating pathways for cardiac disorders, mouth disorders, and infections unrelated to neutropenia. Additionally, order set integration to automate the clinical pathway process in the electronic medical record is in progress.[Table: see text]

A solution to reducing avoidable emergency department visits: Implementation of an outpatient oncology acute care clinic

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Background: Emergency Department (ED) utilization by oncology patients accounts for more than 4.5 million visits in the United States annually, leading to hospitalization four times the rate of the general population.1,2 Many ED visits are the result of symptoms related to cancer or cancer treatment that can be managed on an outpatient basis. Unnecessary admissions lead to possible delays in cancer treatment and increased burden on healthcare resources.3 Simmons Acute Care (SAC), an advanced practice provider (APP)-led clinic, was established in August 2020 to provide an alternative model of oncology care to address these issues. Methods: A multidisciplinary team of key stakeholders was formed to develop an action plan. Institutional data was reviewed to identify the timing and volume of ED visits by oncology patients. Clinic hours were set Monday through Friday, 7:00am – 7:00pm, and referrals were made from primary oncology providers. Evidence-based clinical pathways were developed to standardize patient management, and a data collection plan was implemented to measure outcomes. Internal communications to patients and presentations at staff and faculty meetings occurred to inform patients and clinical staff/providers. Results: From August to December 2020, 165 patient visits were completed in SAC, 141 patients discharged home, 14 patients directly admitted to the hospital, and 10 patients transferred to the ED for a higher level of care. Based on data from 2020, the average cost of an ED visit for an oncology patient was $5,500 and increased to $28,500 if the patient is admitted. Patients with hematologic and gastrointestinal malignancies represented approximately 30% of all visits. Gastrointestinal symptoms were the most frequent presenting chief complaint. Conclusions: Supporting oncology patients in the ambulatory setting provided a reduction in admissions and unnecessary ED visits, leading to cost savings/avoidance to the patient and health system. Based on internal cost analyses, there are potential savings of over $2 million to the organization during this 5-month period. Additional studies are underway to assess patient satisfaction, as well as the economic impact for patients. 1. Rui PKK. National Hospital Ambulatory Medical Care Survey: 2015 emergency department summary tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf 2. Hong AS, Froehlich T, Clayton Hobbs S, Lee SJC, Halm EA. Impact of a Cancer Urgent Care Clinic on Regional Emergency Department Visits. J Oncol Pract. 2019;15(6):e501-e509. doi:10.1200/JOP.18.00743 3. Roy M, Halbert B, Devlin S, Chiu D, Graue R, Zerillo JA. From metrics to practice: identifying preventable emergency department visits for patients with cancer. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. Published online November 7, 2020. doi:10.1007/s00520-020-05874-3

Botulinum Toxin for Side-Effect Management and Prevention of Surgical Complications in Patients Treated for Head and Neck Cancers and Esophageal Cancer

The management of head and neck cancers (HNC) and esophageal cancer (EC) is complex and often involves multiple modalities of treatment, including chemotherapy, radiation therapy, and surgery. The side effects associated with these therapies and disease processes are extensive. A literature review was performed to evaluate the use of botulinum toxin as an intervention for side-effect management in patients with HNC and EC. Specific adverse events reviewed included salivary function (hypersalivation, fistula, hyposalivation) and gastrointestinal motility (esophageal stricture, delayed gastric emptying after esophagectomy). Published results demonstrate an improvement in hypersalivation and, when botulinum toxin was used as an adjunct to treatment, a reduction in symptoms associated with salivary fistula, or an inappropriate communication between the salivary gland and the skin that causes the leakage of saliva through the skin. Positive effects were also demonstrated in regard to esophageal stricture and equivalent effects in the management of gastric emptying to prevent complications after esophagectomy when compared to currently available interventions. However, the potential for increased symptoms associated with botulinum toxin injection related to its use in the management of gastric secretions was noted in one of the studies reviewed.

Comparing Outcomes of Genetic Counseling Options in Breast and Ovarian Cancer: An Integrative Review

PROBLEM IDENTIFICATION

Genetic counseling is vital in helping people at high risk for hereditary breast and ovarian cancer (HBOC) make informed decisions to undergo BRCA testing. Many people, particularly those in rural locations, lack access to these services. This review examines evidence to determine if remotely delivered genetic counseling via telephone or telemedicine is an effective alternative to in-person counseling for people who are at high risk for HBOC.
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LITERATURE SEARCH

A literature review was completed by searching PubMed, SCOPUS, and CINAHL® databases.
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DATA EVALUATION

151 articles were identified from the search, and 7 were included in the review.
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SYNTHESIS

Patients' BRCA knowledge acquisition, cancer-specific distress, anxiety, depression, and satisfaction with mode of counseling delivery were equivalent between in-person and remotely delivered counseling groups. Genetic testing rates were significantly higher in participants receiving in-person counseling. Remotely delivered genetic counseling was more convenient and less expensive. Mixed outcomes existed regarding counselor-patient communication. 
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IMPLICATIONS FOR PRACTICE

The demand for genetic counseling will grow as advances in cancer genomics reveal genes that may contribute to cancer predisposition. Innovative delivery models are necessary to ensure that all people have access to care.