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Precision Medicine for NSCLC and the Role of APPs

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: So, I’m fortunate enough now to be joined by my fabulous thoracic nurse practitioner, my advanced practice provider, who I work with together treating lung cancer patients at our center. Rasheda, thanks for joining.

Rasheda Persinger, AGNP-C: Thank you, Dr. Levy.

Benjamin P. Levy, MD: Lung cancer, we talk about this all the time in clinic, how complex things are with lung cancer. And just 10 or 15 years ago, where everyone got chemotherapy, we’re now moving into the era of targeted therapies, immunotherapies, and this whole idea of precision medicine with targeted therapy. Can you kind of go over just briefly the targets that we generally test for in our clinic and then we can talk about the drugs as well?

Rasheda Persinger, AGNP-C: Absolutely. So, generally, we’re doing the NGS on EGFR, ALK rearrangement, and ROS1, and then even the PD-L1 status, which is on the tissue as well. So, it’s very important, and patients are coming with that knowledge, right?

Benjamin P. Levy, MD: Yes, they want it.

Rasheda Persinger, AGNP-C: Knowing what is being tested for, are we testing this? So, it’s very important from an APP standpoint to understand what these mutations are.

Benjamin P. Levy, MD: Yes. So, you mentioned the NGS, or the next-generation sequencing, that we do and just high level, the EGFR, the ALK, the ROS, the RET, the BRAF, and the PD-L1 as well. So, just talking about targeted therapies, patients hear a lot about them. We have multiple targeted therapies approved now. Specifically, in the EGFR space, we’ve witnessed some changes recently. Can you talk just a little bit about this?

Rasheda Persinger, AGNP-C: Sure. It has been great change, because in an EGFR world, we’ve had first- and second-generations, and here recently with…

Benjamin P. Levy, MD: Tagrisso (osimertinib).

Rasheda Persinger, AGNP-C: It has really improved symptom management, having the understanding of what it’s indicated for, and recently in the last couple of weeks, even for first-line treatment. So, that is very amazing.

Benjamin P. Levy, MD: We’ve used this drug a lot for patients who were in the refractory setting after getting erlotinib, gefitinib, or afatinib if they were T790M positive.

Rasheda Persinger, AGNP-C: Exactly.

Benjamin P. Levy, MD: And now we’re able to move this frontline for every patient, where if you’re EGFR positive and you have a sensitizing mutation, you can get this drug. Similar thing with alectinib and ALK, right? We’ve got a new indication for that as well. With all of these new targets and all of these new targeted therapies, I think APPs, like physicians, need to maybe be disease specific or disease focused.

Rasheda Persinger, AGNP-C: I absolutely think so, especially in academia. Now, I know in community practice that can be a very big challenge. But definitely with the ongoing new changes that are happening in oncology, especially in lung, it is a need-to-know the disease. It’s no longer safe for us just to know symptom management control. We need to know and have an understanding, on a scientific level, of what is going on with the disease, what does this genetic mutation mean, what does PD-L1 expression mean, what if I have a low expression. You, as an APP, have to know more than just the bare minimum and just the side effects.

Benjamin P. Levy, MD: And it’s not just with targeted therapies—and we’ll talk in a second about how you do this—how you keep up with things. It’s not just with targeted therapies that you have to know this, but with immunotherapy, too.

Rasheda Persinger, AGNP-C: Oh, absolutely.

Benjamin P. Levy, MD: We have new biomarkers for immunotherapies. We have…

Rasheda Persinger, AGNP-C: TMB.

Benjamin P. Levy, MD: Right.

Rasheda Persinger, AGNP-C: It’s just not if they have a PD-L1 status. Now we’re looking at their tumor burden.

Benjamin P. Levy, MD: Burden, mutation.

Rasheda Persinger, AGNP-C: Mutation burden, to see if they will respond with immunotherapy, right? Because patients want to know that precision medicine, they want to know whether or not just because they have a PD-L1, “Am I really going to respond with it?” And I think that’s the next level that we’re going to.

Benjamin P. Levy, MD: It’s such a great comment because I think patients are so motivated to understand what the right drug is for them, and the onus is on us, not just as physicians, but as APPs, to deliver that drug. With targeted therapies, we do next-generation sequencing on every patient. If we identify a target, we give them a targeted therapy. Same thing goes, as you just mentioned, for immunotherapy. We’re doing PD-L1. We may start doing tumor mutation burden. We’re trying to find the right patient with immunotherapy, and sometimes immunotherapy is for all patients up front in combination with chemotherapy. But with all this complexity, you talked about the need for keeping up with it. How does an advanced practice provider, nurse practitioner, as we function as a team, how do we keep up with this? How do you keep up with this?

Rasheda Persinger, AGNP-C: Well, there’s multiple ways. One of them is the importance of pairing with a great physician who is willing to teach, willing to answer questions. But the onus is also on the APP. It’s doing CMEs, whether that’s online, whether that’s in-person, whether that’s conferences, whether it’s reading journal articles. It is important. I can’t say it enough. It is not enough just to know the side effects of the drugs. It is so important to know the disease and the ever-changing treatment options that are coming out. It seems like almost every other week.

Benjamin P. Levy, MD: Yes, it’s overwhelming.

Rasheda Persinger, AGNP-C: Yes, very, yes.

Benjamin P. Levy, MD: It’s overwhelming for physicians, and I think it’s overwhelming for nurse practitioners and advanced practice providers. And that really underscores the importance of doing the things that you mentioned—the CME, the journals—if you are functioning with a physician and it is a team and you are disease specific, even if you’re not. I tell the community physicians, I don’t really envy you. You have a hard job keeping up with multiple different disciplines. I just have to keep up with lung and we still have a hard time. We talk all the time about what to do with patients and trying to understand the conflicting data that we have out there.

Rasheda Persinger, AGNP-C: Absolutely.

Benjamin P. Levy, MD: You’ve mentioned how important it is to keep up with the data. But I think one of the things that you do so well, in addition to keeping up with the data, is you’re the tie-in to the practice a lot of the times. With all the things going on with our patients, talk to me about—I know what you do, but I want to hear it again—the importance of communication for the multidisciplinary team. Because the other segment that we did was with a pathologist and a pulmonologist and how integral they were to the team. You’re the one doing a lot of the communication. So, walk us down that road.

Rasheda Persinger, AGNP-C: It’s that continuity of care. It’s not just the onus on the physician, it is important as the APP. What I usually do, I’m tracking things that we may not have gotten in a timely manner as we suspected or a patient we’re seeing in clinic who needs a more urgent visit with the pulmonologist or if we are needing to do more tissue, did it get to the right place and so forth. So, it is very imperative that it’s not just the relationship with the physician in the medical oncology clinic but also those other interdisciplinaries—pulmonology, radiology, infusion center, even outside primary care—to refer the patients in. Communication is key because there’s no way that it can work seamlessly without being able to communicate.

Benjamin P. Levy, MD: And I think that lung cancer and all cancers for that matter have become so complex that you have to communicate. And I think you touched upon it quite nicely, making sure you do a great job of this, much better than I do reaching out to the pulmonologist, and saying, “Hey, this patient needs their pleural fluid drained.” Specifically reaching out to the pathologist and asking, “What are the moleculars on this patient?”

Rasheda Persinger, AGNP-C: Exactly.

Benjamin P. Levy, MD: And even as you mentioned, the other disciplines, including the primary care physician, make them aware of what’s going on. And also, these second opinions that we get a lot of the times and making sure that we’ve got the tissue. So, I think it’s such a huge role for an APP, not only to be able to learn the data and deliver but also to be the one who’s really marshalling the charge to get all of the information together as best as possible so that the best plan can be made for the patient.

Transcript Edited for Clarity 
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Transcript: 

Benjamin P. Levy, MD: So, I’m fortunate enough now to be joined by my fabulous thoracic nurse practitioner, my advanced practice provider, who I work with together treating lung cancer patients at our center. Rasheda, thanks for joining.

Rasheda Persinger, AGNP-C: Thank you, Dr. Levy.

Benjamin P. Levy, MD: Lung cancer, we talk about this all the time in clinic, how complex things are with lung cancer. And just 10 or 15 years ago, where everyone got chemotherapy, we’re now moving into the era of targeted therapies, immunotherapies, and this whole idea of precision medicine with targeted therapy. Can you kind of go over just briefly the targets that we generally test for in our clinic and then we can talk about the drugs as well?

Rasheda Persinger, AGNP-C: Absolutely. So, generally, we’re doing the NGS on EGFR, ALK rearrangement, and ROS1, and then even the PD-L1 status, which is on the tissue as well. So, it’s very important, and patients are coming with that knowledge, right?

Benjamin P. Levy, MD: Yes, they want it.

Rasheda Persinger, AGNP-C: Knowing what is being tested for, are we testing this? So, it’s very important from an APP standpoint to understand what these mutations are.

Benjamin P. Levy, MD: Yes. So, you mentioned the NGS, or the next-generation sequencing, that we do and just high level, the EGFR, the ALK, the ROS, the RET, the BRAF, and the PD-L1 as well. So, just talking about targeted therapies, patients hear a lot about them. We have multiple targeted therapies approved now. Specifically, in the EGFR space, we’ve witnessed some changes recently. Can you talk just a little bit about this?

Rasheda Persinger, AGNP-C: Sure. It has been great change, because in an EGFR world, we’ve had first- and second-generations, and here recently with…

Benjamin P. Levy, MD: Tagrisso (osimertinib).

Rasheda Persinger, AGNP-C: It has really improved symptom management, having the understanding of what it’s indicated for, and recently in the last couple of weeks, even for first-line treatment. So, that is very amazing.

Benjamin P. Levy, MD: We’ve used this drug a lot for patients who were in the refractory setting after getting erlotinib, gefitinib, or afatinib if they were T790M positive.

Rasheda Persinger, AGNP-C: Exactly.

Benjamin P. Levy, MD: And now we’re able to move this frontline for every patient, where if you’re EGFR positive and you have a sensitizing mutation, you can get this drug. Similar thing with alectinib and ALK, right? We’ve got a new indication for that as well. With all of these new targets and all of these new targeted therapies, I think APPs, like physicians, need to maybe be disease specific or disease focused.

Rasheda Persinger, AGNP-C: I absolutely think so, especially in academia. Now, I know in community practice that can be a very big challenge. But definitely with the ongoing new changes that are happening in oncology, especially in lung, it is a need-to-know the disease. It’s no longer safe for us just to know symptom management control. We need to know and have an understanding, on a scientific level, of what is going on with the disease, what does this genetic mutation mean, what does PD-L1 expression mean, what if I have a low expression. You, as an APP, have to know more than just the bare minimum and just the side effects.

Benjamin P. Levy, MD: And it’s not just with targeted therapies—and we’ll talk in a second about how you do this—how you keep up with things. It’s not just with targeted therapies that you have to know this, but with immunotherapy, too.

Rasheda Persinger, AGNP-C: Oh, absolutely.

Benjamin P. Levy, MD: We have new biomarkers for immunotherapies. We have…

Rasheda Persinger, AGNP-C: TMB.

Benjamin P. Levy, MD: Right.

Rasheda Persinger, AGNP-C: It’s just not if they have a PD-L1 status. Now we’re looking at their tumor burden.

Benjamin P. Levy, MD: Burden, mutation.

Rasheda Persinger, AGNP-C: Mutation burden, to see if they will respond with immunotherapy, right? Because patients want to know that precision medicine, they want to know whether or not just because they have a PD-L1, “Am I really going to respond with it?” And I think that’s the next level that we’re going to.

Benjamin P. Levy, MD: It’s such a great comment because I think patients are so motivated to understand what the right drug is for them, and the onus is on us, not just as physicians, but as APPs, to deliver that drug. With targeted therapies, we do next-generation sequencing on every patient. If we identify a target, we give them a targeted therapy. Same thing goes, as you just mentioned, for immunotherapy. We’re doing PD-L1. We may start doing tumor mutation burden. We’re trying to find the right patient with immunotherapy, and sometimes immunotherapy is for all patients up front in combination with chemotherapy. But with all this complexity, you talked about the need for keeping up with it. How does an advanced practice provider, nurse practitioner, as we function as a team, how do we keep up with this? How do you keep up with this?

Rasheda Persinger, AGNP-C: Well, there’s multiple ways. One of them is the importance of pairing with a great physician who is willing to teach, willing to answer questions. But the onus is also on the APP. It’s doing CMEs, whether that’s online, whether that’s in-person, whether that’s conferences, whether it’s reading journal articles. It is important. I can’t say it enough. It is not enough just to know the side effects of the drugs. It is so important to know the disease and the ever-changing treatment options that are coming out. It seems like almost every other week.

Benjamin P. Levy, MD: Yes, it’s overwhelming.

Rasheda Persinger, AGNP-C: Yes, very, yes.

Benjamin P. Levy, MD: It’s overwhelming for physicians, and I think it’s overwhelming for nurse practitioners and advanced practice providers. And that really underscores the importance of doing the things that you mentioned—the CME, the journals—if you are functioning with a physician and it is a team and you are disease specific, even if you’re not. I tell the community physicians, I don’t really envy you. You have a hard job keeping up with multiple different disciplines. I just have to keep up with lung and we still have a hard time. We talk all the time about what to do with patients and trying to understand the conflicting data that we have out there.

Rasheda Persinger, AGNP-C: Absolutely.

Benjamin P. Levy, MD: You’ve mentioned how important it is to keep up with the data. But I think one of the things that you do so well, in addition to keeping up with the data, is you’re the tie-in to the practice a lot of the times. With all the things going on with our patients, talk to me about—I know what you do, but I want to hear it again—the importance of communication for the multidisciplinary team. Because the other segment that we did was with a pathologist and a pulmonologist and how integral they were to the team. You’re the one doing a lot of the communication. So, walk us down that road.

Rasheda Persinger, AGNP-C: It’s that continuity of care. It’s not just the onus on the physician, it is important as the APP. What I usually do, I’m tracking things that we may not have gotten in a timely manner as we suspected or a patient we’re seeing in clinic who needs a more urgent visit with the pulmonologist or if we are needing to do more tissue, did it get to the right place and so forth. So, it is very imperative that it’s not just the relationship with the physician in the medical oncology clinic but also those other interdisciplinaries—pulmonology, radiology, infusion center, even outside primary care—to refer the patients in. Communication is key because there’s no way that it can work seamlessly without being able to communicate.

Benjamin P. Levy, MD: And I think that lung cancer and all cancers for that matter have become so complex that you have to communicate. And I think you touched upon it quite nicely, making sure you do a great job of this, much better than I do reaching out to the pulmonologist, and saying, “Hey, this patient needs their pleural fluid drained.” Specifically reaching out to the pathologist and asking, “What are the moleculars on this patient?”

Rasheda Persinger, AGNP-C: Exactly.

Benjamin P. Levy, MD: And even as you mentioned, the other disciplines, including the primary care physician, make them aware of what’s going on. And also, these second opinions that we get a lot of the times and making sure that we’ve got the tissue. So, I think it’s such a huge role for an APP, not only to be able to learn the data and deliver but also to be the one who’s really marshalling the charge to get all of the information together as best as possible so that the best plan can be made for the patient.

Transcript Edited for Clarity 
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