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Communicating With the NSCLC Patient

Insights From: Ben Levy, MD, Sibley Memorial Hospital; Andrew Lerner, MD, Sibley Memorial Hospital; Rasheda Persinger, AGNP-C, Sibley Memorial Hospital; Andrea Richardson, MD, PhD, Sibley Memorial Hospital
Published: Friday, May 25, 2018



Transcript: 

Benjamin P. Levy, MD: Communication between the multidisciplinary team is important, and again, I think the APP helps lead that. What about with all of these new drugs available? How does the APP communicate these changes to the patient?

Rasheda Persinger, AGNP-C: That’s very good, because yes, the patient meets with the physician and goes over the treatment plan or what is going to be done. But more times than not, the patient also follows up with the advanced practitioner in terms of other questions that they didn’t ask or they were concerned about asking. So, again, it’s being able to not only read that information, know it for myself, but being able to communicate it on a level that they can understand it, right?

Benjamin P. Levy, MD: How do you set expectations for patients? Patients are coming in a lot of the time—and you and I have talked about this before—they’re hearing about immunotherapy, they’re hearing about targeted therapy. What kind of expectations do you have to set for that patient?

Rasheda Persinger, AGNP-C: Well, you have to be very clear. You have to remind patients that everything that they hear in the news, everything that’s reported in the newspaper, just because it generally says, “For lung cancer,” it may not necessarily be appropriate for their lung cancer because lung cancer is very different. It’s not the same throughout. So, it’s very important to level that type of expectation right up front, so therefore it alleviates some of the concern. But also, it goes back to establishing that relationship, because then they feel comfortable enough to ask you those questions in terms of, “Well, is this for me? Is this not for me?” and being able to communicate why this may or may not be.

Benjamin P. Levy, MD: And I think you highlight something that’s very important, which is that we are functioning together as a team so that patients do feel comfortable with whatever personalized therapy we offer them, whether it be targeted therapy or immunotherapy. We’ve talked about this before on a podcast about the importance of coming together as a team and presenting ourselves together as a team. I usually see the new consults first, but after each consult, I do bring you in and say, “This is my advanced practice provider.” We work together as a team, and that does really instill a lot of confidence, I think, to the patient.

Rasheda Persinger, AGNP-C: It does, yes. It’s very important because then the patient and their caregivers see it as a team. They see that as, “Oh, I can ask Dr. Levy and I can also speak to Rasheda, and they obviously are communicating well with each other,” and I think we display that. It’s not just if we alternate visits and we’re seeing one patient and you’re seeing another. They know that we’re in constant communication about the needs and the concerns in terms of how we give that information to them.

Benjamin P. Levy, MD: Yes, and I think you’ve taught me this about how important that is. And I think we’ve reaped the benefits of it, seeing how patients feel completely comfortable calling you about something versus calling me when an issue arises. And you feel completely comfortable addressing it and making sure the appropriate follow-up is done.

Rasheda Persinger, AGNP-C: Exactly.

Benjamin P. Levy, MD: We’ll talk a little bit more about side effects in a different segment. But with all of these targeted therapies and immunotherapies, you’re wonderful at what we call at our institution the “Chemo teach.” The patient is about to start chemotherapy. They’re not eligible for targeted therapy, or they’re not getting an immunotherapy, and you walk through the side effects. Maybe take us down setting expectations for toxicity for chemotherapy versus targeted therapy versus immunotherapy.

Rasheda Persinger, AGNP-C: Absolutely. That’s a very different ball game, because with chemotherapy, we’re used to it. It’s toxic; it has all of these side effects. You have to come to the office very frequently to check labs and so forth. And then when you move to targeted therapy, you have to reassure the patient that they don’t need to come every week and every 2 weeks. But again, it goes back to, even with targeted therapies, making sure you have that relationship. So, when they only come to see us on a monthly basis, they are comfortable enough to call in to say if there are new symptoms based off of what we reviewed, right? And then with immunotherapy, immunotherapy is its own beast. I can say that because although there tends to not be as many side effects as you see with chemotherapy, it does still have some side effects that warrant immediate attention. You have to make sure that you communicate that with the patient and that you are open. I think that’s one of the big things with the APP, that we can help in this area, especially with immunotherapy in between appointments, because there are new symptoms coming up. Or if there’s new concern, we can bring them in even if it’s not on their treatment day.

Benjamin P. Levy, MD: Yes, and the host of side effects that we’re seeing with immunotherapy with just the thyroid dysfunction, that has been the theme of our week.

Rasheda Persinger, AGNP-C: Yes, it has, yes.

Benjamin P. Levy, MD: As well as diarrhea or colitis. You’ve been very proactive, and I think all of these unique side effects also mean that the APPs have to communicate this with other disciplines to help manage this. If there’s a hepatitis or colitis, there has to be communication to the GI specialist to help treat these patients.

Rasheda Persinger, AGNP-C: Yes, as well as with the endocrinologist. I think we have become best friends with endocrinology in regard to what we feel comfortable managing and what we need to refer out to our endocrinologists.

Benjamin P. Levy, MD: And the hypothyroidism generally is one of those things with immunotherapy that I originally felt comfortable treating, and I still do. But I think, more recently, we’ve had some complexities with some of these hypothyroidisms. It really forces you or myself, mainly you, to reach out to some of these endocrinologists and say, “Hey, look, we need some help here. This patient is on an I-O therapy, they’re doing well, but we have to communicate and be proactive.”

Rasheda Persinger, AGNP-C: Right. It goes back to that communication. It’s a huge piece, not just in your immediate office but in the other areas outside.

Benjamin P. Levy, MD: Yes. So, this has been a fascinating discussion. I think it’s nice to level set how we manage patients up front and what the APP’s role is in really leading the effort in delivering care but also setting expectations for both treatment and toxicities. I think we’ve said this before when we spoke, and I think if we were to have another discussion about the role of the APP in 12 to 24 months, it may be very different. The role continues to evolve, so thanks for being on and talking to me.

Rasheda Persinger, AGNP-C: Thank you for having me.

Transcript Edited for Clarity 
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Transcript: 

Benjamin P. Levy, MD: Communication between the multidisciplinary team is important, and again, I think the APP helps lead that. What about with all of these new drugs available? How does the APP communicate these changes to the patient?

Rasheda Persinger, AGNP-C: That’s very good, because yes, the patient meets with the physician and goes over the treatment plan or what is going to be done. But more times than not, the patient also follows up with the advanced practitioner in terms of other questions that they didn’t ask or they were concerned about asking. So, again, it’s being able to not only read that information, know it for myself, but being able to communicate it on a level that they can understand it, right?

Benjamin P. Levy, MD: How do you set expectations for patients? Patients are coming in a lot of the time—and you and I have talked about this before—they’re hearing about immunotherapy, they’re hearing about targeted therapy. What kind of expectations do you have to set for that patient?

Rasheda Persinger, AGNP-C: Well, you have to be very clear. You have to remind patients that everything that they hear in the news, everything that’s reported in the newspaper, just because it generally says, “For lung cancer,” it may not necessarily be appropriate for their lung cancer because lung cancer is very different. It’s not the same throughout. So, it’s very important to level that type of expectation right up front, so therefore it alleviates some of the concern. But also, it goes back to establishing that relationship, because then they feel comfortable enough to ask you those questions in terms of, “Well, is this for me? Is this not for me?” and being able to communicate why this may or may not be.

Benjamin P. Levy, MD: And I think you highlight something that’s very important, which is that we are functioning together as a team so that patients do feel comfortable with whatever personalized therapy we offer them, whether it be targeted therapy or immunotherapy. We’ve talked about this before on a podcast about the importance of coming together as a team and presenting ourselves together as a team. I usually see the new consults first, but after each consult, I do bring you in and say, “This is my advanced practice provider.” We work together as a team, and that does really instill a lot of confidence, I think, to the patient.

Rasheda Persinger, AGNP-C: It does, yes. It’s very important because then the patient and their caregivers see it as a team. They see that as, “Oh, I can ask Dr. Levy and I can also speak to Rasheda, and they obviously are communicating well with each other,” and I think we display that. It’s not just if we alternate visits and we’re seeing one patient and you’re seeing another. They know that we’re in constant communication about the needs and the concerns in terms of how we give that information to them.

Benjamin P. Levy, MD: Yes, and I think you’ve taught me this about how important that is. And I think we’ve reaped the benefits of it, seeing how patients feel completely comfortable calling you about something versus calling me when an issue arises. And you feel completely comfortable addressing it and making sure the appropriate follow-up is done.

Rasheda Persinger, AGNP-C: Exactly.

Benjamin P. Levy, MD: We’ll talk a little bit more about side effects in a different segment. But with all of these targeted therapies and immunotherapies, you’re wonderful at what we call at our institution the “Chemo teach.” The patient is about to start chemotherapy. They’re not eligible for targeted therapy, or they’re not getting an immunotherapy, and you walk through the side effects. Maybe take us down setting expectations for toxicity for chemotherapy versus targeted therapy versus immunotherapy.

Rasheda Persinger, AGNP-C: Absolutely. That’s a very different ball game, because with chemotherapy, we’re used to it. It’s toxic; it has all of these side effects. You have to come to the office very frequently to check labs and so forth. And then when you move to targeted therapy, you have to reassure the patient that they don’t need to come every week and every 2 weeks. But again, it goes back to, even with targeted therapies, making sure you have that relationship. So, when they only come to see us on a monthly basis, they are comfortable enough to call in to say if there are new symptoms based off of what we reviewed, right? And then with immunotherapy, immunotherapy is its own beast. I can say that because although there tends to not be as many side effects as you see with chemotherapy, it does still have some side effects that warrant immediate attention. You have to make sure that you communicate that with the patient and that you are open. I think that’s one of the big things with the APP, that we can help in this area, especially with immunotherapy in between appointments, because there are new symptoms coming up. Or if there’s new concern, we can bring them in even if it’s not on their treatment day.

Benjamin P. Levy, MD: Yes, and the host of side effects that we’re seeing with immunotherapy with just the thyroid dysfunction, that has been the theme of our week.

Rasheda Persinger, AGNP-C: Yes, it has, yes.

Benjamin P. Levy, MD: As well as diarrhea or colitis. You’ve been very proactive, and I think all of these unique side effects also mean that the APPs have to communicate this with other disciplines to help manage this. If there’s a hepatitis or colitis, there has to be communication to the GI specialist to help treat these patients.

Rasheda Persinger, AGNP-C: Yes, as well as with the endocrinologist. I think we have become best friends with endocrinology in regard to what we feel comfortable managing and what we need to refer out to our endocrinologists.

Benjamin P. Levy, MD: And the hypothyroidism generally is one of those things with immunotherapy that I originally felt comfortable treating, and I still do. But I think, more recently, we’ve had some complexities with some of these hypothyroidisms. It really forces you or myself, mainly you, to reach out to some of these endocrinologists and say, “Hey, look, we need some help here. This patient is on an I-O therapy, they’re doing well, but we have to communicate and be proactive.”

Rasheda Persinger, AGNP-C: Right. It goes back to that communication. It’s a huge piece, not just in your immediate office but in the other areas outside.

Benjamin P. Levy, MD: Yes. So, this has been a fascinating discussion. I think it’s nice to level set how we manage patients up front and what the APP’s role is in really leading the effort in delivering care but also setting expectations for both treatment and toxicities. I think we’ve said this before when we spoke, and I think if we were to have another discussion about the role of the APP in 12 to 24 months, it may be very different. The role continues to evolve, so thanks for being on and talking to me.

Rasheda Persinger, AGNP-C: Thank you for having me.

Transcript Edited for Clarity 
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