Cancer Care and Education in the Era of Precision Oncology

In the era of precision oncology, nurses and advanced practice providers (APPs) do far more than manage chemotherapy or monitor adverse effects (AEs). Today’s cancer care requires a strong understanding of genetics and genomics, as these fields now drive how cancers are detected, treated, and even prevented. Genomic testing is routinely used to identify inherited cancer risks, guide screening strategies, and match patients with targeted therapies.

Samantha Shenoy, MSN, NP, an oncology nurse practitioner who works in multiple myeloma research at the University of California, San Francisco Health, has witnessed how advances in precision medicine have changed the role of nurses and APPs and allowed patients with cancer to have more personalized therapy.

“It’s important for nurse practitioners and other [APPs] to be educated about the types of things that we test for, to understand what genetic abnormalities mean and what their significance is, and to understand how different drugs might target a specific genetic abnormality,” Shenoy said.

She explained that because nurses are often the first to educate, counsel, and support patients through complex decisions, oncology nurses need to be able to clearly explain the purpose of genetic testing and interpret results so they can confidently guide patients through care.

“It’s important for us to truly understand what these tests mean and be able to explain them in a way that helps patients make sense of their treatment journey,” Shenoy said.

Patients’ interpretations of what genetic testing is may vary. By understanding genetic testing, nurses can accurately explain to patients how their results may influence treatment decisions and why certain drugs are most likely to be effective for their type of cancer.

Educating on Safety and AEs

While precision cancer treatments, like targeted therapies and immunotherapies, are often less toxic than traditional chemotherapy, Shenoy notes they also come with their own set of unique and sometimes serious AEs.

“It’s important to explain to patients that, while treatment is working to kill the cancer, [patients] may also experience other [AEs],” Shenoy explained.

Unlike with traditional chemotherapy, AEs of precision therapies can be delayed, long-lasting, or serious since they involve the immune system or very specific molecular pathways. This makes early recognition, patient education, and close monitoring essential, especially since many patients are on oral at-home targeted therapies and need guidance on what requires urgent attention.

Nurses play a vital role in protecting patients on targeted therapies from infection by recognizing these early warning signs and ensuring timely prophylaxis. Before treatment begins, nurses should verify vaccination status, review laboratory values, and report any signs of fever, cough, or rash immediately.

One example of infection risk is seen with rituximab, a targeted therapy that depletes B cells and weakens the immune system’s ability to fight infections. To prevent complications, patients should be screened for hepatitis B before treatment, started on antiviral prophylaxis if they test positive, and monitored closely for signs of viral reactivation or other infections during and after therapy.¹

Unlike traditional chemotherapies, which were designed to attack rapidly dividing cells, no matter where those cells were in the body, Ashley Martinez, DNP, APRN, FNP-BC, AOCNP, CPHQ, NEA-BC, said some of the newer precision therapies are engineered to target specific aspects of cancer cells, reducing severe AEs, thereby enhancing patient safety.

“We know that with [fewer AEs], patients can also have a better quality of life during treatment,” Martinez noted.

Genetic and Genomic Testing: What’s the Difference?

Martinez, director of advanced practice at MD Anderson Cancer Center in Houston, Texas, said patients frequently seek information about precision cancer care, including what it is, how it works, whether it’s right for them, and what genetic testing involves. Nurses, she emphasized, are in a key position to field these questions and help patients understand their options.

“When nurses are equipped with their own knowledge, they can then transfer that knowledge to patients, serving as patient educators and patient advocates,” Martinez said. “Patients may come into an appointment seeking information regarding precision cancer care, and nurses are at the forefront to provide that to our patients.”

Tumor biomarkers are measurable substances, usually molecules such as proteins, genes, or other biological materials found in blood, urine, or other bodily fluids that indicate the presence of cancer.² They are signs that cancer may be present or that a tumor is growing, shrinking, or responding to treatment.

Martinez said nurses can also help identify gaps in care by verifying and making sure the appropriate biomarker testing has been initiated for patients.

“They can be a key member of the team that helps to educate patients regarding biomarker testing and also makes sure what biomarkers have or have not been ordered for that patient,” Martinez explained. “Knowing how to look at pathology, genetic, and genomic testing reports…and how to interpret the results can be a key benefit for nurses.”

For patients with breast cancer, Martinez said this starts with ensuring the estrogen receptor, progesterone receptor, and HER2 biomarkers are reported. Based on those results, along with other characteristics of the patient’s disease, additional biomarker testing may be needed, such as PD-1/PD-L1 status, ESR1 mutation, and PIK3CA status, among others.^2,3

Martinez said patients may come into their first oncology appointment expecting to leave with a treatment plan, not realizing that multiple laboratory draws and additional tumor testing may still be needed before treatment decisions can be made.

“A lot of times, patients will say, ‘My friend had a very similar breast cancer. Why didn’t she receive this specific medication, or why did her oncologist recommend something different?’” Martinez said. “They may not understand that their cancer treatment is personalized and tailored to their own individual tumor profile. Once we explain that, patients feel more confident knowing we are recommending the most effective treatment.”

She added that one of the most common questions she receives is about the difference between genetic and genomic testing.

“It’s important for APPs and nurses to be able to educate their patients that genetic testing is used to identify inherited conditions or mutations, while genomic testing is used to analyze the DNA of the tumor for any mutations that could be driving its growth,” Martinez explained.

Shenoy added that patients often have questions about the terminology on their pathology or molecular test report.

“A patient might ask, ‘What does 17P mean? Is that bad or good?’” she said. “They want to know if they’re considered high risk or standard risk, so it’s important for nurses to help them understand what their test results and any abnormalities mean.”

Standardizing Better Care

Julie C. Martin, DNP, AOCN, FNP-BC, director of research for the Prisma Health Cancer Institute in Greenville, South Carolina, sees cancer patients who are involved in clinical trials and said that precision medicine has greatly expanded treatment options and hope.

“There are ample data available supporting the improved outcomes that patients experience when they are treated with targeted therapy, if their cancer has an actionable tumor variant,” she said. “This biomarker approach also ensures that when we have a therapy that can target an alteration, it provides better outcomes for patients than using our standard, traditional chemotherapy options of the past.”

Most major cancer centers now follow national guidelines that recommend biomarker or molecular testing for many tumor types, especially breast, lung, colorectal, and hematologic malignancies. While not every patient will need the same test, the expectation is that cancers should be molecularly profiled early in the diagnostic or treatment planning process to identify specific mutations or tumor characteristics that can guide treatment decisions.

In addition, Martin noted that precision oncology has significantly expanded and accelerated the use of pharmacogenomics in cancer care. In the past, pharmacogenomic testing mainly focused on how a patient metabolized a drug. Now the focus has shifted toward pharmacogenomic markers that can predict how patients will respond to chemotherapy, immunotherapy, and targeted therapy.

“Based on pharmacogenomics, we can then optimize the dose we’re giving to a patient,” she said. “Maybe the dose can be reduced, thus minimizing adverse AEs, while maintaining treatment efficacy.”

For instance, pharmacogenomics can be used to optimize the dose of therapies such as mercaptopurine or azathioprine in myeloid leukemias based on TPMT and NUDT15 gene testing.⁴

What’s Next for Precision Oncology?

To stay ahead of the curve in precision cancer care, Shenoy encourages nurses to continuously expand their knowledge in genetics, genomics, and emerging targeted therapies, especially within their field of specialty.

“The field is constantly evolving, so it’s important to keep up with research guidelines...and [engage] in ongoing discussions with colleagues, including physicians,” said Shenoy.

Martin emphasized that there is a growing need for more standardized and consistent use of genetic and genomic testing in cancer care. Despite national guidelines, such as those from the National Comprehensive Cancer Center, that recommend genetic testing, practices still vary widely between institutions. Not all patients undergo testing, which Martin said could result in missed opportunities for screening recommendations.

“Recent reports show that [less] than 7% of patients with cancer received germline testing early in their diagnosis, and we absolutely need to do better,” Martin said. “A positive result not only guides additional testing, it allows us to educate family members about [preventive] care.”

References

1. Kelesidis T, Daikos G, Boumpas D, Tsiodras S. Does rituximab increase the incidence of infectious complications? a narrative review. Int J Infect Dis. 2011;15(1):e2-e16. doi:10.1016/j.ijid.2010.03.025
2. Zhou Y, Tao L, Qiu J, et al. Tumor biomarkers for diagnosis, prognosis and targeted therapy. Signal Transduct Target Ther. 2024;9(1):132. doi:10.1038/s41392-024-01823-2
3. Turner BM, Katerji H, Zhang H, Hicks DG. Biomarker and multigene assay testing in ER positive, HER-2 negative breast carcinomas: an international guidelines-based approach. Hum Pathol Rep. 2021;26:300574. doi:10.1016/j.hpr.2021.300574
4. Relling MV, Schwab M, Whirl-Carrillo M, et al. Clinical Pharmacogenetics Implementation Consortium Guideline for Thiopurine Dosing Based on TPMT and NUDT15 Genotypes: 2018 Update. Clin Pharmacol Ther. 2019;105(5):1095-1105. doi:10.1002/cpt.1304