We once lived in a world where we believed insurance would cover any and all out-of-pocket costs. Sadly, those days are gone—especially for those with cancer, given that the cost of cancer drugs has escalated in the past 10 years, as have patients’ expected out-of-pocket costs. The cost for insurance has also escalated, with more patients facing higher premiums, higher deductibles, and higher co-pays. In 2016, Scott Ramsey, MD, and colleagues found that patients with cancer who face bankruptcy are more likely to die than patients who don’t.

 Interesting to note is that patients with prostate cancer facing bankruptcy were almost twice as likely to die as those not facing medical debt, and those with colorectal cancer facing bankruptcy were 2.5 times more likely to die.

Financial toxicity refers to the out-of-pocket expenses that patients incur during and after cancer treatment. It can affect quality of life and even prevent patients from receiving their cancer treatment.

 We know that patients often do not willingly share their economic hardship. Many will suffer in silence as they try to decide whether to pay for their medication or use the money to put food on the table for their family. Today, research continues to support the need for all members of the healthcare team to initiate a conversation with their patients. Oncology nurses are in an excellent place to start this dialogue, and an understanding of who might be at risk is critical to facilitating this conversation. Patients at high risk for financial toxicity include those who:

• Self-pay, are uninsured, or have Medicaid or Medicare without secondary insurance

• Have advanced and/or metastatic disease

• Are a member of a minority population

Equally important is helping patients understand the new terms associated with the financial cost of cancer care.

All costs not covered by an individual’s health insurance

Amount paid for each healthcare service, such as a doctor appointment or a prescription, after meeting the yearly deductible

 Percentage of costs paid for a service that health insurance covers after the deductible is paid

 Amount an individual pays for covered medical care before the health insurance plan begins to pay

 The share of cost covered by insurance that patients pay out of pocket; generally includes deductibles, coinsurance, co-payments, or similar charges; does not include premiums, balance billing amounts for non-network providers, or the cost of noncovered services

The cost of cancer care is very personal and may explain why many patients do not initiate this discussion. Many patients are reluctant to start a conversation that includes finances or cost of care. Not only is it embarrassing, but patients may also be afraid that by sharing details about financial toxicity, they may not receive the best treatment. Helping patients overcome this fear and enabling them to engage in these conversations is just as important as shared decision making for treatment planning.

Nurses should acknowledge financial toxicity and address it during patient visits. Some have found it helpful to share that many people face challenges when paying for their cancer treatment. Remind patients that the cost of cancer treatment has escalated and that reimbursement is not what it once was. Be an advocate for your patient by asking, “Are you concerned about the cost of your care?” Even if the patient responds that they aren’t, you have will have opened the door to future discussions about financial options that may be available to them should the time come. As we come together, we can help to ensure our patients no longer suffer in silence.

Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as a risk factor for early mortality among patients with cancer. 

. 2016;34(9):980-986. doi: 10.1200/JCO.2015.64.6620.

Zafar SY, Abernethy AP. Financial toxicity, part I: a new name for a growing problem. 

Articles

Professionally Speaking

Oncology nurses are in an ideal position to initiate a conversation about patients’ financial fears.

Nurses Should Address Financial Toxicity With Patients

When Ana Adriazola, DNP, RN, AGPCNP-BC, graduated in 2017 from George Mason University in Fairfax, Virginia, with her doctorate, she knew her future was in oncology. So she applied to the Post Graduate Fellowship in Oncology Nursing program offered at The University of Texas MD Anderson Cancer Center in Houston.

“I wanted to immerse myself in the oncology field to ensure I had exposure to all aspects of treatment and care,” says Adriazola, who started working as a hospital secretary on the oncology unit at Virginia Hospital Center in Arlington. After earning her bachelor’s degree in nursing, she worked as a nurse in the same unit.

When the highly competitive MD Anderson program was launched in 2005, it was the first of its kind in the country. Today, similar programs exist, including the Seattle Cancer Care Alliance’s (SCCA) advanced practice provider fellowships in both oncology and bone marrow transplant for recent NP and physician assistant (PA) graduates.

The 1-year program combines classroom learning with hands-on experience. Nurse fellows also prepare to take the Advanced Oncology Certified Nurse Practitioner (AOCNP) exam to earn an AOCNP credential.

“I’ve had the opportunity to see how departments such as palliative care and psychology work as part of a multidisciplinary team in cancer care,” Adriazola says. “I’ve also learned about the policy side of oncology by attending a national oncology conference and authoring an academic manuscript to be published in a peer-reviewed journal.”

Each fellow chooses an area of specialization during the last half of the program. For Adriazola, that meant working in genitourinary (GU) care. At the end of the fellowship, she accepted a job in GU oncology at MD Anderson.

ADVANCED PRACTICE NURSES JOIN PHYSICIAN ASSISTANTS IN UNIQUE FELLOWSHIP

Shahin Carter, MS, PA-C, heard about the SCCA fellowship after graduating last year from the PA program at Heritage University in Toppenish, Washington. The 1-year comprehensive fellowship, held in conjunction with Fred Hutchinson Cancer Research Center and the University of Washington, launched in 2017 and offers 3 recent PA or NP graduates the chance to experience intense clinical subspecialty training.

“I started my fellowship in October and have completed rotations in hematology malignancies, palliative care, the pain clinic, and inpatient care,” Carter says. “I’m currently starting a 3-month rotation in outpatient care and bone marrow transplants.”

Carrie Anne Graham, MSN, ARNP-BC, who serves on the fellowship committee at SCCA, says the paid fellowship program was launched to train the next generation of PAs and NPs to provide highly specialized care in the oncology field. Graham notes that within the next decade, PAs and NPs are expected to play a critical role in meeting the projected demand for oncology services. A study commissioned by the American Society of Clinical Oncology predicts that the demand for oncology visits will increase by 48% by the year 2020, whereas the visit capacity is expected to increase by only 14%.

 Reasons include an aging population, a growing number of cancer survivors, and expanding treatment options that may require an increase in visit frequency.

“Other fellowship programs tend to be either PA or NP centric, but we wanted to take a teambased approach,” says Tanisha Mojica, ARNP, who also serves on SCCA’s fellowship committee.

FELLOWSHIP OPENS THE DOOR TO COMPLETE ONCOLOGY CARE

Carter learned how to work as part of a multidisciplinary care team to improve patient care. Mojica says the program is designed to help fellows learn leadership skills and gain confidence in their roles so they can hit the ground running and succeed in their jobs. “Our fellowship program removes the pressures of on-the-job learning that many NPs and PAs face when they accept a job directly out of graduate school,” Mojica says.

Also, Mojica adds, NPs who complete a fellowship or a residency program typically have an advantage over other advanced practice nurses when applying for jobs. Because the fellowship speeds up the learning curve, it also prepares them to take on different roles in oncology care and opens up opportunities for advancement and higher salaries.

“We have a nationally recognized clinical trial and transplant program at SCCA, so fellows are learning about cutting-edge treatments,” Graham says. “Our curriculum covers the different malignancy groups and offers didactic time, seminars with mentors, and a better understanding of hematologic malignancies.”

When devising their fellowship program, the SCCA committee worked with other hospitals that offered similar fellowship programs, Graham notes. “We modeled our fellowship in part after the MD Anderson program. We also worked with Seattle Children’s Hospital to learn about their combined APP fellowship program for PAs and NPs interested in pediatrics,” she says.

“We ask our fellows for feedback on the program on a weekly basis and how we might make adjustments to the curriculum and ensure there is a cohesive relationship between fellows and their mentors,” Graham says.

FELLOWSHIPS BENEFIT BOTH NURSES AND HOSPITALS

“Fellowships offer nurses an experience beyond what they learn in most graduate programs,” Mojica says. “They also benefit hospitals by preventing burnout among new nurses, reducing turnover, and improving hospital performance.” Carter admits that if not for the fellowship, she would have gone directly from graduate school to working on an oncology unit.

“The fellowship provides a supportive environment where I can be exposed to all the facets of oncology care,” Carter says. “I’ve had the chance to work as part of a multidisciplinary team and care for patients [with cacner] and their families. It’s definitely made me a better clinician.”

Vogel WH. Advanced practitioners in oncology: meeting the challenges.

. 2010;1:13-18. doi: 10.6004/jadpro.2010.1.1.2.

Feature Story

Nurses can “hit the ground running” in their careers thanks to fellowship programs.

Oncology Fellowships Prepare Nurse Practitioners to Take On Multiple Roles

Patient navigation is uniquely distinguished as both a mediator and advocate role that attempts to optimize interactions between patients and their healthcare systems.

 Its genesis in cancer care dates to 1990, when the American Cancer Society proposed efforts to improve care for the medically underserved with cancer.

 Specifically targeting poor African American women who commonly presented with latestage breast cancer, Harold Freeman, MD, began the nation’s first patient navigation program at Harlem Hospital in New York, New York.

Currently the core role of an oncology navigator encompasses many competencies. These include reducing barriers to needed services in a timely manner, assisting with logistical orientation, providing practical and educational guidance with decision making, and offering emotional support, all while acting as a liaison between the patient and the healthcare system.

Throughout nearly 3 decades of implementation, the scientific basis of patient navigation has evolved within a more contemporary time frame. Most of the research to date on patient navigation has been qualitative, but the National Cancer Institute—funded Patient Navigation Research Program (PNRP) is the first multicenter clinical trial exploring the benefits of patient navigation compared with usual care.

 Focusing on data from 4 cancers (breast, cervical, colorectal, prostate), the PNRP is charged with establishing the evidence base to design, implement, and evaluate a generalizable patient navigation program specifically for vulnerable populations. Recent findings have established navigation-specific positive outcomes such as higher screening rates, faster time to diagnostic resolution, improved patient satisfaction, increased follow-up care, and enhanced quality of cancer care.

However, experts have cited numerous challgnes relative to the navigator role’s continued evolution. First, capturing the financial benefit and cost-effectiveness of patient navigation can be complicated. Second, the field is still working to develop role competencies and training standards. Third, where navigation fits in with different populations remains a question. For example, is the lay navigation model preferable for certain patient cohorts? Finally, there has been difficulty when it comes to the creation of patient navigation programs for non— disease-specific populations, such as survivorship and end-of-life care. Successful approaches to these quandaries are critical to sustain and advance the navigator role within cancer care. In 2018, the National Policy Forum of the National Academies of Sciences, Engineering, and Medicine (NASEM) held a workshop titled “Establishing Effective Patient Navigation Programs in Oncology.” Its intent was to identify potential strategies to enhance the future of navigation initiatives. Six major directives were identified:

• Provide effective navigation services throughout the oncology care continuum

• Improve education for patient navigation • Coordinate and manage patient navigation teams

• Assess needs and resources for successful patient navigation

• Address policy challenges and opportunities for making navigation affordable

Within these, 36 suggested approaches were outlined. Four especially struck me because of their alignment with other contemporary foci in cancer care.

One involved fostering self-care management for patients receiving navigation support. Emphasizing care of self positions patients as collaborators with the cancer care team rather than solely as recipients of treatment. Another was deploying telehealth tools to enable patient communication with care providers, including virtual visits. The use of novel communication technology is the future of healthcare, and its potential should be part of contemporary discussions concerning our ability to keep patients connected with their providers. A third suggestion entailed tailoring navigation programs and training to fit the culture of the communities they serve. This idea recognizes that 1 size does not fit all and can enhance engagement with patients when community norms and beliefs are built into interventions. I found the final strategy of significant importance. It recommended establishing a metric-tracking system at the onset of a navigation program. This requires starting with the end in mind and offers testimony to how critical capturing outcomes and outlining evaluation criteria are to the growth of patient navigation initiatives.

Patient navigation will very likely be a pillar of future patient-centered cancer care. NASEM’s blueprint of proposed strategies serves as a guide to enhance this practice and science. Collaboration is needed among the varied stakeholders driving this initiative. These include practitioners, data and financial experts, community agencies, public health departments, insurers, and patients and their family caregivers. As the essential role of patient navigation is considered for the future, results from this NASEM workshop help guide the way for a successful journey.

Wells KJ, Battaglia TA, Dudley DJ, et al; Patient Navigation Research Program. Patient navigation: state of the art or is it science? 

. 2008;113(8):1999-2010. doi: 10.1002/cncr.23815.

Freeman HP, Rodriguez RL. History and principles of patient navigation. 

 2011;117(suppl 15):3537-3540. doi: 10.1002/cncr.26262.

Freeman HP. The history, principles and future of patient navigation: commentary

. 2013;29(2):72-75. doi: 10.1016/j.soncn.2013.02.002.

Cantril C, Haylock PJ. Patient navigation in the oncology care setting. 

. 2013;29(2):76-90. doi: 10.1016/j.soncn.2013.02.003.

Ko NY, Snyder FR, Raich PC, et al. Racial and ethnic differences in patient navigation: results from the Patient Navigation Research Program. 

 2016;122(17):2715-2722. doi: 10.1002/cncr.30109.

Freund KM, Battaglia TA, Calhoun E, et al; Writing Group of the Patient Navigation Research Program. Impact of patient navigation on timely cancer care: the Patient Navigation Research Program. 

. 2014;106(6):dju115. doi: 10.1093/jnci/dju115.

Lopez D, Pratt-Chapman ML, Rohan EA, et al. Establishing effective patient navigation programs in oncology [published online March 18, 2019]. 

Nurse's Notes

Patient navigation is set to be a pillar within cancer care, but challenges remain.

Navigating the Navigation Science

Nancy McClung, PhD, RN - Photo credit: Mike Glatzer

What if preventing cancer were as simple as getting a shot in the arm? That is the reality for over 90% of cancers caused by the human papillomavirus (HPV).

 However, statistics from the Centers for Disease Control and Prevention (CDC) reveal that less than 50% of the US population within the targeted age range has received all recommended doses of the HPV vaccine.

 Oncology nurses must stay attuned to the critical vaccination information, including prevalence and prevention, treatment and immunization, and future advances.

HPV infections affect nearly every sexally active person at some point in their life. Although many infections are asymptomatic and resolve without treatment, others are implicated in the 10,800 cases of cervical cancer, 12,900 cases of oropharyngeal cancer, 5900 cases of anal cancer, 3300 cases of vulvar and vaginal cancer, and 900 cases of penile cancer diagnosed in the United States every year. Additionally, about 300,000 new cases of high-grade cervical (precancerous) lesions are identified annually through screening.

 When given before exposure to the virus, the HPV vaccine effectively prevents over 90% of these occurrences. It is the only vaccine currently available for the prevention of cancer.

Nancy McClung, PhD, RN, epidemic intelligence service officer and nurse epidemiologist with the International Center for Immunization and Respiratory Diseases, Office of Infectious Diseases, at the CDC in Atlanta, Georgia, is part of a team involved in policy work and research into the impact of the HPV vaccine in the United States. At the 2019 Annual Epidemic Intelligence Service Conference, she presented the results on the prevalence of HPV infections in female patients in the United States. Since 2006, when the vaccine was introduced, adolescent vaccination-preventable HPV infections have decreased by 86%. For women aged 20 to 24 years, the decline has also been significant, at 71%.

 These numbers reflect steadily increasing vaccination rates, although the HPV vaccine is still given less than other, more established vaccines. In 2013, the team began monitoring HPV vaccine—preventable infections in male patients; they expect to see similarly encouraging results as data become available. The most common HPV-caused cancer in male patients occurs in the oropharynx. “We know HPV causes cancer because we find HPV in all kinds of anogenital cancers, including cervical, anal, penile, vulvar, and vaginal. The virus is detected through biopsy only after becoming cancerous,” McClung said.

Most HPV-caused cancers cannot be detected in the precancerous stage; cervical cancer is the exception and can be detected earlier through screening and subsequently treated. “Parents can prevent cancer in their children by vaccinating them. Providers can prepare and plan for vaccinating adolescents the same day and same time as other routine vaccinations, such as tetanus and meningitis. This vaccine is working. We are confident that it will prevent cancer.”

Recommendations for the HPV vaccine were approved in 2006 for female patients and in 2011 for male patients. Because the vaccine works best before exposure to the virus, parents should have their children vaccinated before they are sexually active. It bears repeating that HPV is a very common virus with a high risk of exposure at some point in an individual’s life. McClung stressed that the vaccine is preventive, not therapeutic; it will not cure the infection or cancer.

Although 3 variations of the HPV vaccine are available, only 1 is currently used in the United States. The earlier quadrivalent vaccine (2006- 2015) protected against HPV types 6 and 11 (anogenital warts) and 16 and 18 (most types of HPV cancers), whereas the 9-valent vaccine (2016-present) protects against the same strains as well as 5 additional types.

The CDC recommends routine HPV vaccination at age 11 or 12 years, although clinicians may start it in children as early as age 9. Two doses are recommended for most people starting before their 15th birthday, with the second dose given 6 to 12 months after the first. Patients require a third dose if the first 2 doses were given less than 5 months apart.

Teens and young adults who start the series between ages 15 and 26, as well as immunocompromised individuals aged 9 to 26 years, should receive 3 doses of the HPV vaccine, with the second dose given 1 to 2 months after the first, followed by the third dose 6 months later. The CDC also recommends HPV vaccination for individuals already sexually active or exposed to HPV to protect against other types of the virus. Vaccinated individuals not only protect themselves from HPV infection but also indirectly protect those who are unvaccinated. This is known as herd protection, and cost-effectiveness models predict that reductions in HPV infections in unvaccinated men and women are likely, given enough numbers of vaccinated individuals.

The HPV vaccine is extremely safe. Adverse reactions are similar to those of other vaccinations, with the most common being pain, redness, and swelling at the injection site and, less frequently, mild fever. The vaccine is available to every child in the United States, and nurses at all levels of care and care settings can be the voice to the public for the HPV vaccine and its role in preventing cancer.

SIPULEUCEL-T AND PROSTATE CANCER TREATMENT

Clinicians are also using vaccines to treat cancer. Sipuleucel-T (Provenge) was approved by the FDA in 2010 as a first-line treatment option for men with metastatic, minimally symptomatic, castrate-resistant prostate cancer. Meredith Morgan, PhD, a nurse practitioner at the University of Michigan’s Cancer Center in Ann Arbor, specializes in genitourinary cancer. She spoke with Oncology Nursing News® recently about the benefits of sipuleucel-T.

“The mechanism of action of this autologous, cellular immunotherapy—though somewhat unknown&mdash;directs the immune system to attack prostate cancer cells,” Morgan said. “Sipuleucel-T does not influence PSA [prostate-specific antigen] levels, and we don’t see a real difference in scans of patients treated with the vaccine, making it challenging to measure its success. What we do know, however, is that patients tend to live an average of 4.1 months longer when treated early. Sipuleucel-T is well tolerated, and adverse reactions are generally mild and short-lived. The vaccine is not useful, however, for patients with end-stage cancer. And although it is quite expensive, the cost of the drug is often covered by insurance.”

Since the introduction of the vaccine in the prostate cancer space, the FDA has approved several alternative oral medication options. Assessing patient appropriateness for sipuleucel-T is important, as other therapeutic treatments may be equally as effective in providing survival benefits. Once a clinician has identified a patient as a candidate for sipuleucel-T, the preparation of their personalized therapy begins.

“The first step takes place in an apheresis center, such as those operated by the Red Cross, where a vein assessment is completed. Patients with inadequate veins will require an implanted port; patients with adequate veins will have a dialysis-type catheter inserted, 1 in each arm. Over a 3- to 4-hour period, blood is removed, immature antigenpresenting cells are collected, and the blood is returned to the patient,” Morgan explained. “The collected cells are shipped to the drug manufacturer’s lab, where a protein [immune cell activator] is added to boost the immune power of the cells. After a 3-day turnaround time, these super white cells are shipped out and courier-delivered to the infusion setting, where they are given the same day,” Morgan added.

The treatment plan comprises 3 rounds of apheresis and infusion. The entire process is time sensitive and requires precise coordination to ensure the drug is delivered and administered within the allotted window. Nurses should instruct patients to drink plenty of water before the apheresis process, avoid caffeine, eat a calcium- rich breakfast, wear clothing with loose-fitting sleeves, and arrange for a ride home, as the blood removal procedure can be exhausting.

Nurses administering the immunotherapy wear standard personal protective equipment and follow the same safety checks as those for other transfusions. Opening the medication box, spiking the drug, and beginning the procedure of infusion must be completed within a tight time frame. Verifying patient information and the expiration date and time requires 2 registered nurses as a safety measure. Adherence to protocols provided by the drug manufacturer is a key responsibility for nurses who are administering the therapy. Infusions are given using primary intravenous tubing with no filter.

Adverse events associated with sipuleucel-T are generally infusion related. Patients are premedicated with acetaminophen and diphenhydramine and instructed to continue taking acetaminophen post infusion as needed for chills, fever, muscle aches, and joint pain. These symptoms are shortlived and much more tolerable than reactions associated with traditional chemotherapy. Some patients, such as those receiving steroid medications or with hematologic disorders, are not candidates for this treatment.

IMMUNIZATION CONSIDERATIONS FOR PATIENTS WITH CANCER

Routine vaccination is also an important consideration for patients with cancer, as some vaccine-preventable diseases may be linked to worse outcomes in this population. The CDC issues routine vaccination recommendations for patients based on age, evidence of immunity, and special criteria, such as immunocompromising conditions.

 Based on the severity of those conditions in patients, clinicians may need to delay vaccinations. Activated vaccines should be given prior to immunotherapy or chemotherapy or following completion of treatment.

Influenza can lead to serious complications in patients with cancer. As such, nurses must stay abreast of current developments regarding flu vaccines to ensure they provide accurate information to their patients about the timing and effectiveness of vaccine administration.

Research, development, and testing of vaccines for the treatment of a variety of cancers are ongoing. These therapies include tumor cell vaccines, antigen vaccines, dendritic cell vaccines, and vector-based vaccines. Vaccine study is under way for common cancers such as glioblastomas and other brain cancers, lymphoma, melanoma, and breast, cervical, colorectal, kidney, lung, pancreatic, and prostate cancers. This is an exciting area of research with the potential to significantly affect oncology nurses’ perception and use of vaccines for patients with cancer. Nurses will be at the forefront of patient education as new treatments and preventive measures become available. As clinical trials move forward, oncology nurses will also be instrumental in guiding patients through the enrollment process and sharing information as it is disseminated throughout the healthcare community. The day may come when preventing a variety of cancers is truly as simple as a getting a shot in the arm—the idea may not be that far-fetched after all.

Why is HPV vaccine important? Centers for Disease Control and Prevention website. 

. Updated March 10, 2017. Accessed May 9, 2019.

HPV vaccination coverage data. Centers for Disease Control and Prevention website. 

. Updated August 23, 2018. Accessed May 9, 2019.

Infographic: screening won’t protect your patients from most HPV cancers. Centers for Disease Control and Prevention website. 

cdc.gov/hpv/hcp/hpv-important/more-than-screening-infographic.html

McClung N. Human papillomavirus prevalence among females in the United States, overall and by race/ethnicity, National Health and Nutrition Examination Survey, 

 -2006 and 2013-2016. Presented at: 68th Annual Epidemic Intelligence Service Conference; April 29-May 2, 2019; Atlanta, GA.

Vaccination schedules & recommendations. Centers for Disease Control and Prevention website. 

cdc.gov/hpv/hcp/schedules-recommendations.html

Malagon T, Laurie C, Franco E. Human papillomavirus vaccination and the role of herd effects in future cancer control planning: a review. 

2018;17(5):395-409. doi: 10.1080/14760584.2018.1471986.

Table 1. Recommended adult immunization schedule for ages 19 years and older, United States, 2019. Centers for Disease Control and Prevention website. 

cdc.gov/vaccines/schedules/hcp/imz/adult.html

. Updated February 5, 2019. Accessed May 10, 2019.

Shah M, Kamboj M. Immunizing cancer patients: which patients? which vaccines? when to give? 

Cover Story

Nurses must stay attuned to the critical vaccination information, including prevalence and prevention, treatment and immunization, and future advances.

June/July 2019

Nurses Should Address Financial Toxicity With Patients

Oncology Fellowships Prepare Nurse Practitioners to Take On Multiple Roles

Navigating the Navigation Science

Vaccinations Are Changing the Landscape of Cancer Prevention and Treatment