Burbage Underscores Value of Multidisciplinary Research Following ASCO 2023

Darcy Burbage, DNP, RN, AOCN, CBCN

Patient education and symptom management are key to improved patient outcomes, according to Darcy Burbage, DNP, RN, AOCN, CBCN.

Burbage, who is an oncology clinical nurse specialist, and who has served as director-at-large of the Oncology Nursing Society, was selected as one of the featured voices of the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, with many oncology nurses following her tweets to track trending presentations from this year’s meeting. In an interview with Oncology Nursing News®, Burbage highlighted several presentations from the meeting and which key takeaways oncology nurses can seek to implement into practice.

“It is difficult to highlight only a few presentations that will have the largest impact on oncology nursing practice as data presented at ASCO have many implications for improving patient care outcomes and therefore impacting oncology nursing practice,” she said. “However, the ones that I found [most] impactful were those that provided an interdisciplinary approach and included the voice of the patient.”

Oncology Nursing News: Which presentations from ASCO 2023 do you feel will have the largest impact on oncology nursing practice? Why?

Burbage: Data presented by Deborah Schrag, MD, MPH, FASCO from Memorial Sloan Kettering Cancer Center (MSKCC) from the [phase 2/3] PROSPECT trial [NCT01515787] demonstrated that some individuals living with locally advanced rectal cancer that respond to neoadjuvant chemotherapy can safely forego radiation therapy prior to surgery. Key findings were, that after 5 years, there was no statistically significant difference between the 2 treatment groups in any of the end points studied, meaning that radiation therapy can be safely omitted before surgery if the tumor responds to treatment with modified FOLFOX6 chemotherapy.¹

Radiation therapy can have significant short- and long-term toxicities that negatively impact quality of life, such as infertility, ovarian failures, the need for a temporary ostomy, diarrhea, cramping, fecal incontinence, and bladder problems. Results from this study gives patient alternative treatment options. Oncology nurses can educate their patients regarding results of this important study to empower them to advocate for the most up to date and evidence-based care.

The keynote address delivered by Monica Bertagnolli, MD, FACS, FASCO, director of the National Cancer Institute, where the 8 goals of the National Cancer Plan were discussed, will be another opportunity for oncology nurses to make an impact through the cancer continuum. To achieve the Cancer Moonshot goals, oncology nurses will be instrumental in efforts to address risk reduction, promote early detection, as well as in eliminating inequities in care by delivering optimal care as well as key members of the oncology workforce.

What was your impression of the D-TORCH study (CTRI/2021/01/030592)? Could you comment on the findings and whether you think it could affect practice? Were there any other abstracts form the symptoms and survivorship track that stood out of you?

Making capecitabine as tolerable as possible includes managing one of its most well-known adverse effects; hand foot syndrome (HFS)—also called palmar–plantar erythrodysesthesia. HFS impacts patient functioning and can cause reduce quality of life because of its wide range of painful symptoms, such as hyperpigmentation of the palms of the hands and soles of the feet, skin thickening, loss of sensation, peeling, blistering, bleeding, ulcerations, and swelling.²

Data presented from the D-TORCH study during the 2023 ASCO were exciting. The new findings suggest [that providers] may make capecitabine more tolerable for patients through a novel dosing schedule and reduce HFS by combining capecitabine with topical diclofenac. According to Dawn Hershman, MD, MS, FASCO, of Columbia University “…this will improve the patient experience and allow individuals to remain on effective therapies longer.” I concur with this statement.

[I also enjoyed] “Building a Needs Assessment Toolkit for Survivorship,” which was presented by Nicole Stoudt, DPT, CLT-LANA, FAPTA from West Virginia University Cancer Center, and Michael Jefford, PhD, MBBS, MPH from Peter MacCallum Cancer Centre. In this session, several actionable, real-world experiences were presented by internationally renowned survivorship researchers. According to Jefford and Stoudt, [although] most survivors initially adjust to life after treatment, others experience a broad range of short and long-term effects ranging from ongoing physical concerns such as pain and fatigue, psychosocial issues such as a change in relationships, lack of support, anxiety, and posttraumatic stress; and financial issues such as loss of insurance and income. Ongoing assessment using a standardized process within your clinical practice setting is critical to assessing and responding to patient-reported outcomes (PROs). Oncology nurses are essential to this role in helping select appropriate PRO measures and in helping link individuals living with and beyond cancer to support services within the health system and to those in the community.³

Addressing social determinants of health was another theme highlighted throughout this session. All oncology clinicians—oncology nurses, nurse navigators, community health care workers, physicians—need to be aware of this important area that impacts all aspects of the patient experience and is associated with reduced access to care and effective treatment. The ASCO Social Determinants of Health Task Force is working to further address these areas to define, operationalize and intervene to ensure equitable care is provided. As oncology nurses are usually the first to recognize an individual’s social needs and nonmedical factors that influence health outcomes, interdisciplinary collaboration with multiple stakeholders including patients, community organizations, and other members of the cancer care team will help to build trust and address the systemic changes that need to occur.

Another session covered integrative oncology. Patients living with cancer frequently ask oncology nurses about dietary supplements along with other mind-body therapies such as yoga, acupuncture, to improve symptom management as well as to improve their overall quality of life. This interdisciplinary panel included members of the Society of Integrative Oncology (SIO) and reviewed the urgent need to educate oncology clinicians on the fundamentals of integrative oncology along with provided actionable guidance that summarized the evidence. In order to counsel patients on the safety and efficacy of integrative therapies it is key to establish trust by normalizing the conversation, provide accurate information and facilitate informed decision making.

More attention is being given to the financial toxicities related to cancer. Were there any presentations in this arena that you found insightful? What were some of the key takeaways for providers?

Several sessions and abstracts discussed financial toxicity. As part of the session addressing social determinants of health, Ruth Carlos, MD, MS, discussed financial toxicity through cancer care delivery research. In addition to the costs of care incurred because of cancer treatment, Carlos discussed the indirect costs of care, such as transportation, child/elder care, food, rent, and losing wages because of treatment. Out of pocket expenses, co-pays, co-insurance, along with delayed visits, medical testing, and medication nonadherence were all discussed. Suggestions provided to address financial toxicities include discussing financial toxicity at multidisciplinary tumor boards, normalizing the conversation between patient and clinicians, and incorporating financial counselors/navigators within the clinic workflow.⁴

In another session, prominent MSKCC radiation oncologist and financial toxicity expert, Fumiko Chino, MD and Mr. Nishwant Swami, MPH, presented their research exploring financial toxicity among Hispanic individuals living with and beyond cancer by their country of origin. It is estimated that nearly half of patients with cancer, including survivors of cancer, experience financial toxicity, Not surprisingly, even individuals with health insurance experience financial burdens related to the costs of care, with even higher rates documented in those coming from low socioeconomic status populations, disinvested communities, and/or those that face barriers because of the additive burdens of the social determinants of health. They recommend implementing targeted solutions to vulnerable populations, better characterization of financial toxicity in communities that disproportionately experience these burdens by disaggregating outcomes and disparities within the Hispanic/Latino/Latinx diaspora to acknowledge the heterogenous social determinants of health affecting these populations and move toward impactful change.

Along the same lines, could you comment on the use of tools PROs and digital health monitoring apps? How are these measures providing more comprehensive care? What gaps still exist?

Implementing technology, eHealth tools, wearables, and informatics to improve cancer care delivery was another prevalent theme at ASCO 2023. [One session] was on improving interoperability by standardizing oncology coding data. This was presented by several prominent oncologists, including Travis Osterman, DO, from Vanderbilt University Medical Center.⁵

Some examples for using the electronic health record including using it to document progress and end of therapy treatment summaries, [improving] clinical trial end points—including adverse event reporting and assisting with prior authorization. Implementation considerations for all digital health tools include early engagement of all stakeholders, resource planning and workflow mapping, in addition to real time technical support, along with staff training, and ongoing enhancements.

Integrating wearables and machine learning [into clinical practice] requires institutional support, including [potential] burdens with costs and response times. It may require hiring additional staff, such as oncology nurses, to monitor and respond to patient portal requests and ePROs in oncology practices. Additional gaps include access to technology and including the voice community- based and advocacy organizations, social services, patients, and primary care clinicians within the digital space to ensure key information is collected and equitable care is delivered throughout the cancer continuum.

Is there anything else you feel would be relevant for nurse colleagues to know?

Maintaining a healthy workforce is important. An educational session that included distinguished oncology nurse scientist, Christopher Friese PhD, RN, AOCN, addressed grief, burnout, and wellbeing in the practice of oncology. This session provided evidence-based solutions to reduce professional burnout and bolster well-being on the oncology team that I found useful.⁶

In summary, ASCO is the largest oncology conference in the world, with over 35,000 in person attendees gathering in Chicago over the first weekend in June. There were over 200 in-person sessions and over 5000 posters! As a first-time attendee, it was everything that I expected it to be and more. It was inspiring to be surrounded by so many colleagues all looking to learn from each other and take back to their respective communities practice changing research to improve the care of patients living with cancer. If you have the opportunity, I recommend attending. I am already looking forward to next year!

Reference

1. Schrag D, Shi Q, Weiser MR, et al. PROSPECT: a randomized phase III trial of neoadjuvant chemoradiation versus neoadjuvant FOLFOX chemotherapy with selective use of chemoradiation, followed by total mesorectal excision (TME) for treatment of locally advanced rectal cancer (LARC) (Alliance N1048). J Clin Oncol. 2023;41(suppl 17):LBA2. doi: 10.1200/JCO.2023.41.17_suppl.LBA2
2. Khan QJ, Bohnenkamp C, Monson T, et al. Randomized trial of fixed dose capecitabine compared to standard dose capecitabine in metastatic breast cancer: the X-7/7 trial. J Clin Oncol. 2023;41(suppl 16):1007. doi:10.1200/JCO.2023.41.16_suppl.1007
3. Stout N, Jefford M. Meet the professors: nuts and bolts—building a needs assessment toolkit for survivorship. Presented at: 2023 ASCO Annual Meeting; June 2-5, 2023; Chicago, IL.
4. Carlos R. Improving cancer outcomes by addressing social determinants of health.Presented at: 2023 ASCO Annual Meeting; June 2-5, 2023; Chicago, IL.
5. Osterman T.Implementing innovation: informatics-based technologies to improve care delivery and clinical research. Presented at: 2023 ASCO Annual Meeting; June 2-5, 2023; Chicago, IL.
6. Hlubocky FJ, Lyckholm LJ, Friese CR. Addressing grief, burnout, and well-being in the practice of oncology.Presented at: 2023 ASCO Annual Meeting; June 2-5, 2023; Chicago, IL.