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
Benjamin P. Levy, MD: We’ve talked about the role of the advanced practice provider in that initial phase, making a diagnosis, and setting expectations. But the APP role really is front-and-center as the treatment begins. Discuss your role for patients as they start treatment with chemotherapy, immunotherapy, and targeted therapy, specifically about toxicity management and setting expectations as they go through each of these modalities.
Rasheda Persinger, AGNP-C: I think at first you have to delineate between which treatment, whether it be chemotherapy or targeted therapy or immunotherapy, because they’re going to differ. With chemotherapy, as we know, you come in for certain visits and do labs. But with targeted therapy, it is not only once we order the medication and they receive it, it’s also letting the patients know they need to come back in 2 to 4 weeks for that initial, “How are you tolerating the drug?”
Benjamin P. Levy, MD: “Are you adherent to the drug? Are you taking the drug?”
Rasheda Persinger, AGNP-C: Exactly. Even before we get there, we need to also assess their level of comfort and their level of willingness to do that. Because you don’t want to send them with oral. Everyone thinks oral is less problematic because you don’t have to come into the hospital. But it’s more responsibility on the patient. I go over their coming back in 2 to 4 weeks after starting the medication. From there, we tend to see you on a monthly basis, warranting that there’s no worsening symptoms and there is no need to come in earlier. But letting them know that if there are symptoms that arise outside of that timeframe, that you should be more than willing to give us a call and we’ll get you in. That’s with targeted therapy. Now, immunotherapy is a whole different topic. They come in anyway for an infusion and so forth.
Benjamin P. Levy, MD: Every 3 to 4 or 2 or 3 weeks, yes.
Rasheda Persinger, AGNP-C: Exactly. And I think even more so with immunotherapy, letting them know if you have diarrhea, still tell us. It doesn’t mean that we’re going to stop treatment. We just need to monitor that before it gets to a grade 4 or something like that. Because this is advanced cancer, they want this treatment as long as they can receive it. Some patients feel nervous that if they tell the physician or the APP that these symptoms occur, then treatment may be stopped.
Benjamin P. Levy, MD: That’s a good point. I think you raise a lot of good points in that, one being informing the patient to be proactive and letting us know about their symptoms. Them being proactive doesn’t mean they’re coming off of the drug. I think you also do a nice job with the patient in terms of setting the follow-up and giving them a sense of what to call about.
Rasheda Persinger, AGNP-C: Exactly, because I have seen that if you do not set that standard of when you need to call, that sometimes you get some unnecessary phone calls or you get visits to the emergency room that may not warrant it. I think that’s why with the chemotherapy teach class, we can go over things in a slower mechanism with caregivers there if possible, so that everyone is on the same page in terms of what the side effects are and when to call us.
Benjamin P. Levy, MD: I tell patients generally that if they leave have any questions at all to call. I think it’s helpful to set some metrics to say, “These are the things that you need to look out for.” With perhaps targeted therapy, it’s rash and diarrhea, but maybe not so much now with Tagrisso being frontline therapy. There’s not a lot of side effects with that drug. But just with immunotherapy, the diarrhea is so important to assess, as well as acute shortness of breath. And we’ve had a lot of profound fatigue that ends up being fulminant hypothyroidism.
Rasheda Persinger, AGNP-C: Yes, exactly.
Benjamin P. Levy, MD: Those are things I think for which the APP is front-and-center. And not with toxicity management only. I think as patients go through the treatment continuum, you’re also oftentimes with me informing them how you think the drugs are working and what to expect if they’re benefitting from the drug.
Rasheda Persinger, AGNP-C: Right. And I think also that follow-up, or that carrying out the treatment plan, is making sure that patients and their caregiver know the other resources in our facility. It’s not just the physician and the APP or the pulmonologist or the pathologist. There is also the social worker and the dietitian. I think that’s a great role of what the APP does well. We assess the needs that may not necessarily be clinical, but social as well.
Benjamin P. Levy, MD: Right. Yes, and I think having the right people at a center who can afford these services is great.
Rasheda Persinger, AGNP-C: Exactly.
Benjamin P. Levy, MD: Having the acupuncturist, the dietitian, and the social worker working at the center is also helpful. Communication is key not only for the APP at the beginning of treatment but really reaching out to other services as well. Not just the pulmonologist and pathologist but the dietician, the social worker, and the pain and palliative care specialist are all necessary.
Rasheda Persinger, AGNP-C: Exactly.
Benjamin P. Levy, MD: Just briefly talk about how you interface with the pulmonologist or other disciplines as patients are going through treatment, because you do a lot of this. Patients come in and they have issues that arise as their cancer may grow or not grow or have toxicities. How important is it that the APP is keeping in contact with the team?
Rasheda Persinger, AGNP-C: It’s very important. I know that at our institution, the communication and the relationship that we have already formed with Dr. Lerner is amazing, because at any time I could be seeing a patient and have concerns about, “Is there is some pleural effusion there? Do we need to tap?” or “Is something seen on the scan?” It’s nothing for me to give him a call, and he’s so responsive. And I think that’s very important, because once again, that improves patients’ outcomes.
Benjamin P. Levy, MD: It does. And I think we have that data that the more team approach you have, the better the care that is delivered to that patient. When we prescribe these targeted therapies, which is another issue with communication, oftentimes we have to reach out to the pharmacists.
Rasheda Persinger, AGNP-C: Absolutely. Not only is reaching out to the pharmacist necessary, but also reassuring the patient. Sometimes, yes, we put the prescription in, but it may take 5 to 7 business days, which I can imagine is frustrating for the patient. Not only is reaching out to the pharmacy required, but the pharmacy also has to contact the insurance company. And if there is some delay, perhaps if it can’t be dispensed from my institution, then it has to be outside sourced. That delays the time of treatment which can be nerve-racking for a patient who is newly diagnosed.