Utilizing Advanced Practice Providers to Their Full Scope in Oncology

Host, Dr. John Sweetenham, associate director of Clinical Affairs at UT Southwestern Harold C. Simmons Comprehensive Cancer Center, and Dr. Sandra Kurtin, director of Advanced Practice and Clinical Integration at the University of Arizona Cancer Center, discuss the future importance of advanced practice providers to the oncology workforce and how to enhance their role in cancer research. Transcript:  Dr. John Sweetenham: Hello. I'm John Sweetenham, the associate director of Clinical Affairs at UT Southwestern's Harold C. Simmons Comprehensive Cancer Center, and host of the ASCO Daily News podcast. Today we'll be discussing the role of advanced practice providers in oncology and their future importance to the oncology workforce.     I'm delighted to welcome our guest, who's a former colleague of mine, Dr. Sandra (Sandy) Kurtin, the director of Advanced Practice and Clinical Integration and an assistant professor of Clinical Medicine at the University of Arizona Cancer Center. Dr. Kurtin is also the president and founding board member of the Advanced Practitioner Society for Hematology and Oncology and an associate editor for the American Society of Hematology News. Sandy, it's great to renew our acquaintance and to have you on the podcast today.     Dr. Sandy Kurtin: Thank you, and I'm delighted to be here.     Dr. John Sweetenham: Before we start, I should mention that my guest and I have no conflicts of interest relating to our topic today. Full disclosures of all guests on the podcast are available on our transcripts, asco.org/podcasts. So Sandy, workforce shortages have been a concern in oncology for some time now and there has been a concern expressed in the literature and especially by ASCO probably for more than 5 years now--suggesting that the oncology workforce, or at least the physician workforce, is diminishing and we really need to be looking at new opportunities in terms of who comprises the workforce in the future.     In addition to a growing and aging population in the United States and an increasing incidence of cancer, we also see new and emerging therapies and technologies which increase the number of cancer survivors. So, it seems more important than ever that we utilize all of our oncology workforce, and particularly advanced practice providers (APPs) to therefore scope in oncology. Based on the assumption that we would expect much of that APP practice in the future to be independent practice, what do you think, Sandy, of the cancer services where APP led services can offer the best opportunity?     Dr. Sandy Kurtin: I think that one of the really remarkable things that I've come to realize—I've been doing this for 37 years—is that we do have not only a growing cancer population, but we have a population of patients that are living much longer, thankfully, with their cancer, and as a result, become more and more complicated patients that require much more specific and complex care, and it really does take a full team. And so, I think using everyone to the full scope of their licensure is really critical to maximize any team. This takes a team.     So, using the word ‘independent,’ I think of that we are always collaborative as members of the interdisciplinary multidisciplinary team, but we can exceed and take the lead in a number of areas that I think are really critical given that population of patients. One of those things are symptom management clinics. I know we, in our practice, are part of the Oncology Care Model (OCM) initiative and we know that keeping people out of the ER and the urgent care settings, out of the hospital, is really critical for any practice and for patients.     And so, running symptom management clinics, same day outpatient clinics, having that same agility in an inpatient APP-supported practice is really important. There's been a lot of work overtime in survivorship clinics and continuity clinics overseeing infusion services. I know in our practice we more or less run a day hospital.     We have people there 12 hours a day and they're very sick and we're providing that level of service in an outpatient setting, granted that's an academic setting. And then there are some growing areas that are niches in genetics and benign hematology. So, I think there are a lot of opportunities that we are beginning to realize and hope to see grow going forward.     Dr. John Sweetenham: Yeah. Very interesting to hear what you say there, and a lot of those overlap with the initiatives that we're introducing UT Southwestern as well. And I'm grateful for you to pick up on the independent practice because I think obviously, we're all at our best when we are part of a team and I think your point is very well taken, of course, there are many aspects of what we do now that can be APP-led. Do you have any thoughts about procedure clinics or specific procedures where you think APPs could be taking the lead?     Dr. Sandy Kurtin: Oh, sure. So, we do, in my practice—well, I've done close to 30,000 bone marrow biopsies in my career.     Right? So, a lot. And I think that—so clearly there are areas where APPs do run procedure clinics and what I have found in doing as many as I've done is the more you do, the better you get and that's better for everybody, the patient, the sample, all of it. And it may be more efficient to have a group of people that do it regularly. Obviously, we still need to train our fellows and other colleagues, but I think that is something that is growing both in surgical oncology and medical oncology for sure.     Dr. John Sweetenham: So, those of us who advocate for expanding APP practice and expanding our APP workforce still encounter some barriers to doing that, as I'm sure that you have as well. Could you comment a little bit on that, on what you think are barriers that prevent us from having APPs reach their full potential in terms of the oncology workforce and any thoughts you have about how we can overcome those barriers?     Dr. Sandy Kurtin: Sure. So, I think probably the biggest barrier in my mind is the lack of understanding and that we are part of a team and it's the ever-looming relative value units (RVU), productivity measures, people trying to meet those metrics. And I think as we move toward value-based based care models where [it] is less driven by visit volume and more driven by outcomes for practices, it will become inevitable to have this interdisciplinary team.     And until we get to the point where if you're a physician [and] I'm working with you as your APP colleague and you're held to a certain RVU, then there's the sense of, well, if I give that to you then that takes away from me. So, rather than having internal competition, which I think is still unfortunately prevalent because we haven't moved away from that on a national level, but I think we will have too inevitably.     I think practices will begin to understand the value of bringing everyone up to their full potential, both in terms of direct patient care and all of those indirect care functions that have to happen to make a practice successful. So, we'll get there, but it's going to take some time, and that lack of understanding presents a barrier. Along with that comes some of the legislation—Medicare rules. Some of those were expanded during COVID-19 because we needed to maximize access to care. We've really tried to negotiate and advocate for keeping those expanded access to care initiatives in place post-COVID-19, even though we're not post-COVID-19, unfortunately. So, I think things are shifting, but we have a ways to go and that lack of understanding and that internal competition still presents a problem.     Dr. John Sweetenham: Yeah. Just changing gears a little, I think clinical trials, as we would recognize, are really a core part of our mission not just as academic medical centers, but as community oncology centers as well and, of course, they're crucial to our advancing patient care. And there are a number of studies, and without going into too many numbers here, there are a number of studies that have looked at the role that advanced practice providers play in clinical research, and particularly in recruiting eligible patients to clinical research.     There was one relatively recent study published in the JADPRO which just last year, which looked at APPs and I think it surveyed a number of APPs at academic centers. And 70% of these APPs said that they approach eligible patients about clinical trials, but not on a regular basis, and it seemed as though most APPs felt that they have more to offer in the space of clinical trials. What do you see as opportunities there? Again, do you think there are barriers that are preventing APPs from making a really solid contributions to clinical trial treatments and accrual and what could we do to elevate the APP role?     Dr. Sandy Kurtin: Sure. So, that study (DOI: 10.6004/jadpro.2021.12.5.2), a colleague Crista Braun-Inglis and was a collaborative effort between ASCO and ACCC and APPSHO, the Advanced Practitioner Society of Hematology Oncology—I happen to be the current president and founding board member of that—really brings to light the sense of I think comfort, really, with clinical trials. There's been, luckily, this robust, scientific discovery, new drugs approved on a regular basis. And as a result of clinical trials, every therapy we have comes as a result of clinical trials, and this is crucial for patient participation.     But I think if the majority of the people in that study that participated were—65% of them were in a community practice setting where they really tend to practice more as generalists as opposed to specialists. So, keeping abreast of all of that knowledge across tumor types, solid tumors, liquid tumors, for standard of care and understanding all the evolving science is really a challenge. So, I think we need to do better at just basic understanding of how a clinical trial is run. I actually published a recent paper on this.     How do you actually run a clinical trial? What is your role as an APP in terms of understanding the phase of the trial? How to do your attestation of adverse events. And we haven't done, I think, a good enough job in preparing our workforce to feel comfortable in taking more of a lead in that role. So, we're working on that in within APPSHO and collaboratively along with ASCO and ACCC and other organizations to really bring that level of knowledge up across the team in general, and I think that's what it's going to take.     Dr. John Sweetenham: Do you think we should all be doing more to promote APP-initiated and APP-led clinical trials? In other words, there are many questions and some of our APPs are now beginning to ask these questions very specifically about the practice or about specific areas of clinical intervention where they're really beginning to take the lead now. And again, what do you think that we can do to help promote that component rather than being a part of the overall clinical trials effort in helping to accrue patients? What do you think we need to do in terms of fostering original research questions from our APP colleagues?     Dr. Sandy Kurtin: That's a fantastic question and something—I think we lose an opportunity—I've been in academics my entire career and so I have been involved in numerous clinical trials. I've been involved in trials that have brought new drugs to market, which is one of the most rewarding things, to me, that we can do is to bring that option forward.     But I think along that way, the group of these clinicians, these APPs that are involved in the conduct of clinical trials—I know for me—sometimes understand the actual clinical management of these patients better than anybody because we tend to see them for those symptom management visits and more frequently than perhaps attendings might be able to accommodate and we can offer this enhanced knowledge. So yes, there's a trial.     This is the drug. Here's the mechanism of action. Here's how this was structured. But how do you actually do it? Right? How do you actually take this new drug and integrate it into your practice in a way that emulates the clinical trial so that you can achieve the outcomes seen in that trial.     And I think that's where APPs have an opportunity to step up and take the lead and say, is there a second question or third or fourth or fifth question in this trial where we can really look at symptom management in a broader scope, or particularly for drugs that have unique symptoms. We've seen many of those in hematology, which is my area of expertise.     Keratopathy as an example, like, what is that and what does that mean and how do we do that. Or some of the other more recent immunotherapies, and really excel in creating standards for management of these adverse events. So, I think that's an area where we could really bring things forward. Our pharmacy colleagues, obviously, also offer a lot along the lines of drug-drug interactions and all of the things that come with their expertise.     Dr. John Sweetenham: Yeah. I think you make a really great point there because certainly in one of my previous institutions for sure which had a very large kidney cancer practice, when a lot of the new agents for kidney cancer emerged, the folks at our institution who had the most expertise in recognizing and treating those toxicities were our APPs that were working with the research team.     So, I completely agree that there's a ton of opportunity there and a lot of untapped resource for the oncology community as a whole. And just closing on that theme in a way, when you look ahead over the next 5 to 10 years, how do you see the future role of APPs in the oncology workforce and what are year overall thoughts about the future? Do you feel optimistic or cautious about APP practice moving forward?     Dr. Sandy Kurtin: I'm an optimist anyway because I've been doing this for a long time and you have to be an optimist, right? So, I think that if we emerge from this COVID-19 pandemic, which we will, and we can get back to focusing on what we do best, I think the future is very bright. I think that I have witnessed a transformation in the collaborative environment and the willingness to—and this is an example of that is just having the opportunity to have this conversation—bring everybody up, because when we're all at our best [when] we do our best work for patients.     And I think as we see more APPs seeking advanced degrees and actually taking the steps that are required, it doesn't just come with a degree. You know that. You have to earn that respect by working hard, demonstrating clinical excellence and expertise, and being invited in, if you will, as a colleague. And so, it isn't something that you just are given, you have to earn it. That's true for physicians as well.   But I think then we all become better, and I actually think the future looks very bright. The science, I say, is crazy good. This is fantastic. The opportunities to prolong patients' lives just continue to get better and better, but we need to get better and better in how [we] preserve all those future treatment options by not letting any adverse event get too bad, so it limits those options going forward. So, it takes finesse and that takes the team, and I think we'll get there. I'm actually very optimistic.     Dr. John Sweetenham: Well, thanks, Sandy. It's great to end on a positive note. And thanks once again for agreeing to come on to the podcast today and for sharing some really thoughtful insights into APP practice now and in the future. And thanks also for all the work that you do both at your local level and nationally to advance the role of APPs in oncology. It's certainly recognized and greatly appreciated.     Dr. Sandy Kurtin: Thank you so much for having me.     Dr. John Sweetenham: And thank you to our listeners for your time today. If you enjoyed this episode, please take a moment to rate and review us wherever you get your podcasts.     Disclosures:   Dr. John Sweetenham:  Consulting or Advisory Role: EMA Wellness    Dr. Sandra Kurtin:  Consulting or Advisory Role: Incyte, Takeda, Abbvie/Genentech, BMS, Astra Zeneca, GSK    Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests' statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.