Nurses Play Pivotal Role in Patient Journey Through Lung Cancer Continuum

Mary Pasquinelli, MS, APRN, associate professor of oncology and urology at Johns Hopkins Medicine

Mary Pasquinelli, MS, APRN

With continuous advances in the lung cancer space, multidisciplinary collaboration and education are needed to ensure that the best treatment plan is selected for each particular case and that patients do well throughout treatment.

Nurses and nurse practitioners often establish relationships with patients before a diagnosis is even confirmed, and they continue to support patients throughout their journey by helping inform the development of an appropriate treatment plan and then ensuring that associated side effects are managed effectively, said Mary Pasquinelli, MS, APRN.

“Often, as a nurse practitioner, I will see that patient throughout their course of treatment and then the oncologist and I work with that patient together to see the patient when they have scans or if they have progression of disease,” Pasquinelli said. “Otherwise, I do a lot of the symptom management and diagnose, prescribe, and treat for any of the side effects.”

With the introduction of new therapies such as checkpoint inhibitors, physicians, including those outside of the oncology space, need to be made aware of how side effects associated with new approaches differ from those experienced with standard of care. Nurses often help communicate that information to ensure the best possible care for patients.

OncLive: Nurses are sometimes the first point of contact for patients with suspected lung cancer. Can you speak to the importance of this?

In an interview during the 2018 OncLive^® State of the Science Summit™ on Non—Small Cell Lung Cancer in Chicago, Illinois, Pasquinelli, a nurse practitioner from the University of Illinois at Chicago (UIC) and director of the lung cancer screening program at UIC, discussed the pivotal role of nurses in lung cancer care.Pasquinelli: Patients come in to our institutions through multiple ways, different referrals. At our hospital, we have the lung cancer screening patient and I will see all the patients that have a Lung-RADS 4 that could be suspicious of lung cancer. I also have a lung nodule clinic, and so, I may see patients in the pulmonary clinic where the patient has a high suspicion of cancer. Then we talk about these patients in the multidisciplinary tumor board and decide which way to biopsy the patient or if we should do more imaging.

Often, I have a relationship with these patients before they actually get diagnosed with cancer and then I’m there when they get diagnosed and I talk with them. One thing that I think is very important is that when we give a diagnosis, we also have a plan for them. They’re not getting called over the phone to get a diagnosis, where they don’t know what’s going to happen next. We give the diagnosis and we talk about a plan right there. We have our lung navigator with us, so he can help that patient get scheduled for the next appointments.

What are some ways that nurse practitioners serve as advocates for their patients?

Often, I do have a relationship with our patients before they come. Sometimes they will call in wanting to get a second opinion, or they’re a new patient, and either I will reach out to them or to a lung navigator just to get some information. Then they kind of know who we are before they come through our door.We work collaboratively with the physician, but I often see the patient by myself when they’re in the clinic getting their chemotherapy—independent of the physician. But if there is a change of therapy or if there’s a question, I always have the oncologist there in the clinic so that I can discuss the case with them. I see the patients independently as long as they’re doing well.

I’m doing a lot of the symptom management, ensuring that they’re doing okay if they have any symptoms and working to resolve the symptoms. Also, I pull in resources, as needed; we distress screen every patient for anxiety and depression and we also have a screen for supportive care.

As developments are made in the field, what should nurses and physicians know about the side effects associated with new treatments?

Many of our patients live in low resource areas and they have a lot of barriers to care and problems with food and security or housing and security, so when I realize that this patient—through our screening and our interviewing—has some issues, I immediately am able to access social work, our palliative care team, other resources, and support groups, to help that patient right at the beginning so that those resources and support help them throughout their whole care continuum.There have been a lot of wonderful new advancements in lung cancer therapy although there are also some new challenges, too. We have all of these new checkpoint inhibitors, immunotherapy drugs, but they also have a big side effect profile that is different from chemotherapy.

It’s really important for physicians, nurse practitioners, and even our infusion nurses, to really understand the side effects of these medications because even though the symptom is the same, how you’re going to treat them might be different. For instance, our lung cancer patients are often short of breath but when they have shortness of breath—is this a pneumonia that’s starting up or is this pneumonitis from the checkpoint inhibitors? You really need to know your patient well, know the symptoms, and be able to work them up appropriately because the treatment is different.

Also, with the checkpoint inhibitors, I often speak to other physicians outside of oncology—the primary care physicians—because of our lung cancer screening program, and I tell them a lot about the side effects. They often know the side effects of chemotherapy—those are pretty well-known—but they don’t know the side effects of immunotherapy and for our primary care providers, we’re often comanaging these patients; often, our patients not only have lung cancer, but they have diabetes, heart failure, or hypertension.

What should the nursing community remember when caring for patients with lung cancer?

It’s important for our primary care providers to understand the side effects of immunotherapy because we’re going to be comanaging them together. I do a lot of awareness and education within our clinic and outside of our clinic.Everybody is different; we have no case that is exactly the same. Each of these cases has a person behind them and it’s so important to treat that patient holistically—not just their cancer, but also mind, body, and spirit—and to be sure that that person has the resources and support to do well throughout their treatment.

Also, it’s important for nurses and nurse practitioners to be sure that they’re being collaborative with their whole team, to be sure that we have the best outcomes and the best support for our patients.