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1. What was the knowledge gained from the article?
I have been aware, as most nurses, of various genetics tests used in oncology care (especially HER2 and BRCA) but Vorderstrausse, Hammer, & Dungan really opened my eyes to the fact that: 1. this will continue to increase in importance year by year and 2. Nurses need to take a strong role in this as we have with many other aspects of healthcare. The part of this article that really spoke to me is in helping patients interpret the importance and impact of the results. I remember my wife’s OB discussing the various perinatal testing available. Before she even went into the details of which tests were available and how they worked, she asked “What are you going to do with the results?” Answering that question helped us eliminate over half of the tests available.
2. Will the research/information in this article change or influence your practice? If so how?
I plan on pursuing CEU’s in oncology genetic testing and its implications because I am not very familiar with it. If a patient asked me a detailed question about it now I would likely tell them to ask their oncologist. I rarely float to the Genetics clinic so I don’t get experience there but I remember them showing me the pedigree charts they fill out.
3. What other questions does the article raise about current practice?
As medicine and healthcare continues to develop, so must our knowledge. Sometimes it seems daunting to try to keep up with it all. Our patients expect and need us to be knowledgeable about all aspects of their care. Luckily there are resources available for us: articles and journal clubs such as this, CEU’s, and experienced colleagues. Sometimes cancer genomics mean family or individual risk of cancer, sometimes it means the genomics of one individual cancer and how to treat that on a case-by-case basis.
4. Do you agree/disagree with the conclusions of the author, why?
I agree wholeheartedly with the authors’ conclusions that nurses need to learn more about genetic testing and counselling for patients. The hard part is getting it accomplished.
One thing Vorderstrausse et al barely mention is commercially available consumer testing. I am very concerned about this as there are already reports regarding the accuracy of various commercial genetic tests (23 and Me, Ancestry, etc). Low levels of accuracy are even more disturbing if we are talking about cancer risks and what actions patients may or may not take based on those results. I get irritated every time I see a pop-up ad, link, or headline that says something like “The 10 signs of brain tumors you can’t ignore,” then proceeds to list 10 symptoms that are vague and could be cause by at least 200 other less serious health conditions. As nurses we have to help our patients navigation fact from fiction AND what to do about it.
Vorderstrasse, A.A., Hammer, M.J., & Dungan, J. R. (2014). Nursing Implications of Personalized and Precision Medicine. Seminars in Oncology Nursing, 30(2), 130-136. https://doi.org/10.1016/j.soncn.2014.03.007
What was the knowledge gained from this article?
The article Implementing Precision Medicine in Community-Based Oncology Programs: Three Models, I particularly appreciated the details on how the three models implemented this data into their daily practice. I know I’ve personally witnessed medical oncologist struggle with how useful this data is when deciding on a treatment regimen especially information from commercial NGS. I also appreciated the acknowledgement that oncologists are generally not aware of the performance characteristics of available tests and may not be directly involved in ordering tests because it often falls to hospital pathology departments.
Vorderstrausse, Hammer, & Dungan I appreciated the reminder of the role of the nurse as a educator and advocator for our patients when it comes to precision medicine.Will the research/knowledge gain from this change or influence your practice? why? Yes I’m definitely going to seek out education opportunities as well so that I can strength my knowledge when it comes to precision medicine. I also will take the advice of Vorderstrausse, Hammer, & Dungan and suggest Health/national human genome research institute and National cancer institute as online resources for additional information on genetic and genomic testing and pharmacogenomics in oncology.
What other questions does the article raise about current practice? Tomorrow brings new treatments and new genetic and genomic testing we must stay current on latest practice because our patient rely on our guidance so much.
Do you agree/disagree with the conclusions of the author, why?
I agree with the generalize message of both of these articles that cancer care is moving forward to personalized medicine will become at the center of the treatment plan and as a oncology nurse evolve with this change by educating myself on current practice.
Levit, L. A., Schenkel, C., Schilsky, R. L., Kim, E. S., McAneny, B. L., Nadauld, L. D., & Levit, K. (2019). Implementing Precision Medicine in Community-Based Oncology Programs: Three Models. Journal of Oncology Practice, 15(6), 325–329. https://doi.org/10.1200/JOP.18.00661
Vorderstrasse, A.A., Hammer, M.J., & Dungan, J. R. (2014). Nursing Implications of Personalized and Precision Medicine. Seminars in Oncology Nursing, 30(2), 130-136. https://doi.org/10.1016/j.soncn.2014.03.007Greg- Thanks for starting the discussion! Really great thoughts. There are so many things to consider with genetic testing. It still surprises me how much the oncology landscape has changed in the short 7 years that I have been in outpatient. When I started in CTU, we were just looking into some targeted therapies and now, especially considering the lung cancer population with PD-1 and PDL-1 inhibitors, we are testing many of the patients and determining their treatments with Standard of Care targeted therapy.
One interesting thing you brought up is understanding the implications of testing. Something that I have discussed with our genetic counselors is the need or not need for life insurance prior to testing, especially if you are testing younger healthy family members. This isn’t something that I would have considered and definitely an important option that you would want to present to patients/family.
Patty- I also found it interesting how different places have implemented PMI. The lab aspects of the 3 models were unique. Are you aware or any of the primary clinic nurses aware of how we get and interpret our results? I thought we sent out Foundation One samples and received the report back (like a 50 page document) and I’m not sure what happens after that. I could be completely wrong since I don’t work directly with a primary team.
Also wanted to share a general resource about the Precision Medicine Initiative through the NCI/NIH if you want a quick read on dedicated oncology resources and plans for the future.
https://www.cancer.gov/research/areas/treatment/pmi-oncology
Implementing Precision Medicine in Community-Based Oncology Programs: Three Models
1. What was the knowledge gained from the article? Working at an academic medical center and research institute definitely has its perks. We are privy to all the cutting edge testing, treatments, and offered many educational opportunities to further our knowledge. I was surprised to learn about some of the challenges that community oncology practices face. These physicians can struggle keeping up with all the advancements being made with testing, treatments, and education, at such a rapid pace. I was also surprised to learn that even when the testing may have been done some practices struggle to retrieve the results and import them into the patient’s medical record.
It makes sense to me why so many patient’s seek out the James, and are willing to wait hours to see physicians here. Many community MDs may have told them their is nothing else that can be done for them. I have even heard horror stories of patient’s receiving the wrong diagnosis or treatment, and I can only assume it was due to lack of available resources and education on the MDs part.
3. What other questions does the article raise about current practice? Knowing what we know about the importance of precision medicine, and how beneficial it is in cancer care treatment, it is maddening to me the costs of these tests and the lack of insurance re-imbursement and coverage. These factors have hindered patients and providers from pursuing/ avoiding testing.
4. Do you agree/disagree with the conclusions of the author, why? I agree that precision medicine is the future and becoming the standard of care. We are fortunate as health care providers to work in an academic setting and research institute, where we are using cutting edge testing and clinical trials. In the last 10 years I have seen cancer treatments evolve to personalized targeted treatment regimens, which are much more tolerable and beneficial to overall outcomes for our patient’s.
Thank you everyone for participating!
1. What was the knowledge gained from the article?
• I have been aware of genetic testing but after reading these articles I will be paying closer attention to if my patients have had it and if not then why? These articles raise a lot of additional questions many of which have already been asked in this discussion and hopefully are answered in the near future.
• 2. Will the research/information in this article change or influence your practice? If so how? I will be paying closer attention if my patients have had genetic testing or not. If not I will advocate for them to have it if appropriate – although with the latest targeted therapy research I think we are heading to a place where every patient should have it done at diagnosis, if we aren’t already there.
Greg- CEU’s are a great option to stay informed. Maybe you could share any that you do with the rest of the group:
3. What other questions does the article raise about current practice? With targeted therapies why aren’t patients tested at time of diagnosis? Of course we know it is not readily covered by insurance so I also ask WHY ISN’T INSURANCE AS UP TO DATE AS THE RESEARCH ON TREATMENTS? When is this going to change?
Gregg and Leah both mentioned the implication on insurance: What if they are tested and healthy family is tested –what will mutations mean for their current health insurance? Will they be treated as a liability before they even develop the disease? What does testing mean for the healthy family’s insurance coverage and premiums?
I feel like every discussion that Insurance is always one of the main obstacles in whatever we are discussing!I completely agree w/ both conclusions. With the direction moving to individualized care, I believe there will have to be new jobs/departments created to manage the education, dealing w/ insurance approvals to name a few.
A lot more critical thinking is going to be needed to manage these individually and continued education for providers and support staff so everyone is always up to date with the latest information.I agree with Kasey- there are lots of horror stories of outside hospitals and treatments/diagnosis and we have to stay up to date on the latest so our patients are offered the best treatment plan. How do these outside providers be encouraged to stay informed and up to date on the research and latest treatment options?
Kasey- I echo your sentiments of all of the incredible resources we have here at The James. As a float, I am amazed every day with the work that we are able to do and the impact with have on people. I will always remember when Dr. Cali. would say No Money No Mission. We are so fortunate that our community has rallied around Pelotonia and the success that has come from this (Total funds as of this morning- $205,171,775)! To think that we are building an Institute for Immuno-Oncology is something really special. Read here if you aren’t aware-
https://cancer.osu.edu/research-and-education/pelotonia-institute-for-immuno-oncology
Mindy and Kasey- You both make mention of the challenges community hospitals face with the ever changing landscape of Oncology care. I think that it will be increasingly important to establish affiliations and share all of the wonderful resources we have here with our regional partners. We currently have 4 affiliations and I imagine that number will continue to grow (Madison County, Wooster Community, St. Rita’s in Lima Ohio, and Clinton Memorial) https://cancer.osu.edu/about/affiliates
It will certainly be a balance in the future. I would love to see a really thorough and effective work ups at The James- continued staging as well. Provide interventions that the community is unable (maybe these places don’t have a surgeon that can perform what the patient needs). But then hand off to local medical oncologists if Standard of Care chemotherapy or other interventions can be handled locally if it is what the patient desires. I often run into people that that travel is incredibly burdensome and they are receiving an infusion that could be done at a local hospital. I’m sure that clinical trials will also extend to the community through our networks as noted on the website. Thoughts on this? I’m sure not everyone shares this same opinion.
Leah – I would love to see the clinical trials extend through our networks but I question how well would it be monitored and would the patients be managed? It would take a tremendous amount of coordinating to be sure the patients and study are monitored 100%. It is promising to see that Nationwide Children’s Hospital and we have collaborated to offer studies to children with Dr Cripe (OSU) overseeing it. That would be a good model to follow if they decide to offer clinical trials at local hospitals. It amazes me daily to see how far patients will travel for care at The James.
Thanks for adding the links in your response!Leah-I do agree that there are many patients that travel an absurd distance to get standard of care regimens, that they could otherwise receive locally. But who knows the conditions of their local facilities or how good the actual care is there? I know myself that I would never want my family that lives in Toledo to get treatment at a local facility. I would encourage them either go to Ann Arbor U of M or come to the James, for research purposes alone, not to mention the education of the Doctors, nurses, and supplemental staff at a these institutions. We strive for excellence at the James and there are many patient’s that have transferred care here because of situations that have happened at a small community hospital. But the burden of travel and expenses alone can cause undo stress and anxiety for patients and their families.
Greg- Please let me know of any CEUs you find on this topic, as I would be interested in them.
I also agree with you about the concern for consumer testing and the accuracy of these tests, along with all the misinformation online. The inaccuracy of the findings could do a lot of emotional and psychological damage to people.
What was the knowledge gained from the article?
Precision medicine clearly can help guide the care of our patients with the best outcome possible for them individually. The ability to order specific exams/tests for a particular diagnosis is phenomenal to me. In my everyday practice I see multiple patients that undergo this and can see how it impacts their care. One specific area I appreciate most is the Oncotype Dx test. The results received impact the patient in whether they will benefit from undergoing chemotherapy or not. The thought of keeping a patient from taking medications that may not have any help for them is so beneficial, not only to keep them from having to experience any bad side effects, but also the cost for the patient.
Will the research/information in this article change or influence your practice.
Due to already using these type of testing with many patient in the clinics I work in, I am not sure it can influence or change my practice. These articles help to reinforce the information and give other resources that I will be able to access if needed.
What other questions are raised by these articles.
I would say that one huge question I have is how will the information gained from completing these tests be managed from an insurance standpoint. Will patients lose life insurance or even their medical insurance if companies somehow find out the results? HIPPAA does exist, but will this be enough to protect our patients and their care with their companies?
Do I disagree/agree with the conclusions of the author?
I do agree with precision medicine. I believe that it really puts the patient first and also can improve their overall outcome. I also agree with the issue on cost and how to make the testing readily available for every patient if need be.
Greg-I too agree with the misinformation on the internet that our patients have access to. It worries me that patients could start diagnosing themselves even more than they do now. The alternative though is that the patient may be able to find clinical trials that are out there that we may not be aware of, thus increasing the likelihood that the patient receives the best treatment possible.
I would say that I too agree with all of you with regards to the amount of information out there that seems to be something that we need to be aware of in our practice. Being able to find CEU’s or other pertinent training would be so helpful. Insurance companies could also benefit from learning this information as this could help lower their overall costs I covering the patient, whether it be utilizing the best treatment plan for that patient or minimizing the care provided that hasn’t been necessary.
Herrington- Foundation One is still one of the outside PMI’s used and just recently I saw one of the medonc physicians treating breast cancer patient include the findings from Foundation One in their progress note. Unfortunately, the information found from Foundation One did not impact the current treatment plan but who knows if this information will help in the future. I greatly appreciated the additional information https://www.cancer.gov/research/areas/treatment/pmi-oncology I shared it with several of my coworkers.
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