Not surprisingly, melanoma nurse practitioner Rajni Kannan is passionate about helping her patients at NYU’s Cancer Institute to fight this devastating disease.

That’s why Kannan, BS, MS, RN, ANP-BC, is excited about the remarkable developments she’s seen in the treatment of metastatic melanoma over the last 5 years—including last year’s FDA approval of two new agents, ipilimumab and vemurafenib.

At the same time, Kannan is determined to reduce the number of patients she sees at the Manhattan facility based at the Langone Medical Center by being an advocate for increased awareness of the dangers of tanning, she told attendees during a presentation at NCONN 2012.

The incidence of melanoma, the deadliest of all skin cancers, is quickly rising, and the disease is responsible for more than 8000 deaths each year, Kannan said, adding that the average survival for melanoma patients with metastatic disease is 7 months, and that 50% of these patients will develop brain metastases. Kannan reminded audience members that exposure to ultraviolet (UV) radiation is a major risk factor for skin cancer, and that the World Health Organization has declared UV-emitting tanning devices carcinogenic.

In discussing ipilimumab (Yervoy), Kannan described the mechanism of the immunotherapy as “amazing.” The treatment is given intravenously every 3 weeks for a total of four doses, and Kannan explained that “patients have had a hard time understanding that they get four doses, and that’s all they get” before returning for tumor evaluations after 12 and 24 weeks and then every 3 months thereafter. Kannan noted that nurses have an important role to play in explaining to worried patients that “this is enough.”

The other new agent, vemurafenib (Zelboraf), is a targeted therapy approved for patients with unresectable or metastatic melanoma who test positive for the 

mutation—approximately 40% of melanoma patients, according to Kannan. Testing for 

 mutational status, she said, must be conducted at a site of metastatic disease, presenting another important role for oncology nurses and navigators: to help patients with earlier-stage cancers understand why they can’t be tested. Moreover, she said, “if you give this drug to patients who don’t have the mutation, you can actually accelerate the disease.”

“Eighty percent of patients respond to vemurafenib, but the question is, for how long?” Kannan noted. In some patients, disease quickly returns, while others do extremely well. “We need to determine why some patients have a sustained response,” she said.

These two agents offer new hope for metastatic melanoma patients, but both have complex side-effect profiles. Nurses are important in this regard, too, Kannan said, since they can share their expertise about the drugs with patients, who often “don’t communicate well about their side effects.”

National Comprehensive Cancer Center guidelines recommend clinical trials as first-line therapy for metastatic melanoma patients, and a number of new agents are under investigation for treatment of the disease, Kannan reported. PD-1, an immune checkpoint inhibitor, is about to go into phase III testing. Researchers are also looking at MEK inhibitors, vaccines, and combination therapies.

This is an area where nurse navigators also can make a huge difference, she said, by helping patients locate not only the right trials for their diseases, but also studies that will accept their health insurance plans. Kannan stays abreast of virtually all relevant clinical trials underway at NYU and elsewhere. “It’s not about us,” she said. “We’ll send patients anywhere to get the care they need.”

Kannan is currently writing a grant application to establish a melanoma survivorship program at NYU. “Survivorship is now a reality in melanoma,” she said, “but we don’t have the magic medicine yet.”

Articles

The incidence of melanoma, the deadliest of all skin cancers, is quickly rising, and the disease is responsible for more than 8000 deaths each year.

New Metastatic Melanoma Therapies Create Hope for Patients, Key Role for Oncology Nurses

One recent development on the minds of NCONN 2012 attendees is the new patient navigation standard announced in March by the American College of Surgeons Commission on Cancer (CoC). Facilities seeking CoC accreditation now need to have a patient navigation process in place by 2015.

Mary Lou Woodford, RN, BSN, MBA, CCM, care coordination program director for the Massachusetts Department of Health, offered practical guidance to the group on how to use the CoC standard to help their institutions design programs that break down barriers and ensure equal access to care in the communities they serve.

	“My Hospital Is CoC-Accredited: What Do I Need to Do to Comply?”

When Woodford hears this question, and she often does, she explains that under 

, facilities will need to demonstrate that they have a process in place that removes barriers to care. This does not mean that facilities have to employ patient navigators; however, Woodford emphasized these key elements:

		Perform a community “needs assessment” to documents disparities and barriers to care for patients in the community

		Identify resources—either on-site or through referral&mdash;to address these disparities / barriers

		Present patient navigation process to cancer committee annually for formal evaluation

		Modify or enhance patient navigation process to address results and recommendations from the committee evaluation

“To do a thorough needs assessment, and to do it well, can take 12 months,” noted Woodford. “Look at your own state’s comprehensive cancer plan. Every state health department has one. They can help you get the data you need for the assessment.”

She emphasizes that CoC is looking for measurable data on what prevents some people from accessing care at a facility and cites community interviews and focus groups as examples of ways to secure the required data. “Bringing in other units, such as cardiovascular or chronic disease specialists, to work with you on the needs assessment may also be an approach that will work for your facility,” Woodford added.

The purpose of the assessment, Woodford explained, is to identify: (1) the needs of the population a facility serves, (2) health disparities in the community, and (3) resources to prevent barriers and improve access to care. Armed with this information, facilities can create building blocks for program development, implementation, and evaluation.

“The assessment is broader than just who comes to your facility,” said Woodford.  “You need to get into the community and find out why some people don’t access care.”

Woodford pointed out that it would be hard for one individual, such as a navigator, to set up this process alone, and suggested engaging a multidisciplinary group at each facility to work on the project. Members of the multidisciplinary team  might include evaluation research, quality improvement, discharge planning, medical records, and community resources.

Despite the extended 2015 deadline, Woodford strongly advised facilities to get started no matter where they happen to be in their own CoC 3-year survey cycle for accreditation. “[The CoC] wants facilities to succeed. If you start working on implementation before the survey staff visit, it will be a great opportunity to get their guidance. We all know what the standard is, and survey evaluators will be looking at your progress.”

“The ultimate goal is to serve the whole community,” concluded Woodford.

For more information on the standards, visit 

Facilities seeking Commission on Cancer accreditation now need to have a patient navigation process in place by 2015.


Annual NCONN Conference

New Metastatic Melanoma Therapies Create Hope for Patients, Key Role for Oncology Nurses

Opportunity Knocks: New ACoS Standard Requires Navigation Process in Place by 2015