Overall, the transition from breast to genitourinary cancer has added depth and dimension to my knowledge of cancer care.
A long career in oncology has been one of the most rewarding and gratifying journeys of my life. Medical oncology has always been my passion and focus, although the settings have varied. I worked most of my 20-year career in outpatient medical oncology with a brief stint in the inpatient setting. The job titles have been “Oncology Nurse” at the community practice, “Staff Nurse” during my inpatient position, and “Nurse Clinician” – both infusion and clinic. Transitioning from one role to another has been exciting with new learning opportunities that helped fill in knowledge gaps and gain expertise.
My biggest transition to date happened in 2022, when I graduated from the AGNP program at Drexel and joined the Genitourinary group at Rutgers Cancer Institute of New Jersey as an Advanced Practice Nurse (APN). This was a significant change on two fronts – a new tumor group and a new role with a wider scope. I was now a “provider” with an independent clinic schedule.
Comparing Treatment Modalities
Having a strong foundation in oncology prepared me for changes within most tumor groups. After 3.5 years of exclusive breast cancer experience, the genitourinary (GU) group had some similarities but many more differences. Breast cancer in women and prostate cancer in men are very similar in that the tumors are hormonally dependent with similar risk factors, gene mutations, and therapy trajectories. Many patients with metastatic disease face bone metastases. However, there is also a growing percentage of long-term survivors in these settings.
Treatment modalities are also similar, although there is more neoadjuvant and adjuvant chemotherapy in breast as a single tumor group. There is higher concurrent chemo-radiotherapy, as well as immunotherapy, in GU oncology. In addition, more classes of oral oncolytics are being used in GU oncology because of the variety of tumors. Breast cancer is 1 tumor type with multiple molecular subtypes, whereas GU is a field that has several tumor types with subtypes under the same umbrella.
Adverse Event Management
Adverse effect management of patients on hormonal therapy is also similar. The major difference is in the patient population, breast cancer was almost exclusively female and prostate cancer is all male. This may not seem like a huge factor but to me, it was a significant shift when dealing with the physical, emotional, and practical aspects of patient care. The other common GU malignancies – urothelial, renal, penile, testicular – also occurred more in males. GU also has a proportionately greater geriatric population than breast. As an RN in breast, I was the first point of contact and gave out my email and direct phone extension to all patients. In GU, since my role is different, I depend on the nursing team to triage and escalate relevant issues.
The Connection Does Not Feel the Same
At a very personal level, I was able to instantly form a connection with most of my patients with breast cancer, even when we had just met. Some of those connections ran very deep and added to the gratification of being a nurse.
In contrast, I have formed a few close connections with my patients with GU cancers, but they lack the same intensity. Could it be that nurses deal with more patient concerns and become close because of that trusting relationship? Or is it that I, myself, am a woman and therefore share a natural affinity to other women, and that this made connection easier in the breast cancer space? Maybe that is one aspect of nursing that I do miss.
The relationship with all my attendings has a similar flavor, even isolating at times, compared to the camaraderie I shared as an infusion nurse. I sometimes feel like a liaison with an increased scope. There is surely a component of role-confusion during the transition for me and the patients as well.
Newfound Prescribing Power
The assumption is that schooling prepares an RN to think like an APN, but in reality, the education for me started when formal schooling was complete! A seemingly simple decision like prescribing an antibiotic for a urinary tract infection was something that I suddenly found intimidating, not because I lacked the information or knowledge, but because of the new license and liability factor. I was now responsible for this person’s well-being and obsessed over details potentially leading to errors. UpToDate and Epocrates became my best friends! I would routinely confer with attendings and pharmacists for possible contraindications and safety issues.
I am fortunate to have found excellent mentors in the GU group that are willing to train, invest in a new APN, and foster independent practice. Working with 3 medical oncologists has given me a unique perspective and advantage of gaining from their individual and collective expertise. Although my previous nursing experience helps tremendously, the wider scope of practice involves independent decision-making, diagnosis, and management of patient issues add much more responsibility. I refer to NCCN guidelines daily for algorithms regarding management, surveillance, and supportive care.
Documentation is by far the most time-consuming aspect of patient care as a provider. In the first 3 to 4 months of starting as APN, each note would take me at least 2 hours. This was partly from lack of experience and learning how to prioritize inclusions and exclusions in the note. Almost a year into practice, things are beginning to come together now, and I am so much more comfortable in my role.
Overall, the transition from breast to GU has added depth and dimension to my knowledge of cancer care. Some crucial factors that have contributed to a smooth transition are a strong foundation and work experience in oncology, continuing education, and opportunities/support available at Rutgers Cancer Institute of New Jersey in partnership with RWJBarnabas Health. I look forward to many more years of service in cancer care.
Sri Kota, MSN, BA, APN, AGNP-C, OCN, is a nurse practitioner in the Urologic Oncology Program at Rutgers Cancer Institute of New Jersey and RWJBarnabas Health, New Jersey’s leading cancer program and only National Cancer Institute (NCI)-designated Comprehensive Cancer Center.