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Highlights from Friday, November 16, 2018

Conference Highlights - 2018 Annual Conference

In anticipation of the full slate of events in store, attendees awakened early for a morning stretch and smoothies before diving into compelling sessions and engaging encounters with industry sponsors. Highlights included insightful presentations on immunotherapy, the NAVmetricsTM study, CAR T-cell therapy, and the American Cancer Society Patient Navigator Tracks.

Immunotherapy Offers Hope to Patients, Oncology Community

For so long, the standard-of-care treatments for cancer have been surgery, radiation, and chemotherapy.

“We slash with surgery, we burn with radiation, and we poison with chemotherapy,” said Carsten Kampe, MD, PhD, FACP, of Texas Oncology. “It sounds horrible, because it kind of is.”

In his presentation on immunotherapy, Dr Kampe explained how by activating the immune system to fight cancer, immunotherapy has provided a new tool in oncologists’ armamentarium.

Although it’s relatively new to the world of oncology, the concept of immunotherapy began in the late 1700s, with the development of the cowpox vaccine. Its most recent innovation was the first chimeric antigen receptor T-cell therapy, approved in 2017, according to Dr Kampe, who also highlighted some of his own contributions to the literature on immunotherapy, made when he was a young scientist at the University of California, Los Angeles (UCLA).

After reviewing the various types of cancer immunotherapies, he provided insight into how the immune system fights cancer. The fundamental property in this fight, Dr Kampe said, is the immune system’s capability to discern “self” from “nonself,” a recognition made by T-cell receptors. As the key players in immune surveillance, T-cells operate with a delicate balance between their accelerators and brakes, which are needed to attack foreign invaders while avoiding excessive activation that can lead to the destruction of healthy cells.

While T-cell receptors have the ability to recognize up to 100 million antigens, because cancer cells are derived from normal cells, they look much like “self” to these receptors. Molecules called checkpoints can assist cancer cells in disguising themselves to avoid detection, thereby keeping T-cells from attacking them. This is where checkpoint inhibitors come in.

In checkpoint inhibition, blockade of PD-1 unleashes the antitumor T-cell response, releasing the brake on the immune system to allow it to fight the cancer. Dr Kampe pointed out that part of the beauty of this process is that once the immune system learns to attack cancer cells, it remembers that and will continue to do so.

Ipilimumab was the first checkpoint inhibitor approved by the US Food and Drug Administration, winning approval in 2011 for the treatment of metastatic melanoma.

“Since then, progress has been fast and furious,” Dr Kampe said.

Joining the ranks of approved checkpoint inhibitors in the following years were nivolumab, pembrolizumab, atezolizumab, durvalumab, avelumab, and cemiplimab. The use of these treatments has shown that checkpoint inhibitors are truly a boon for some patients with cancer.

Dr Kampe cited the example of former President Jimmy Carter, whose melanoma metastasized to his brain at age 90. After undergoing surgery and radiation, then subsequently, treatment with a checkpoint inhibitor, he is cancer-free at 94 years of age.

The impressive success story was followed by a disheartening case study of why checkpoint inhibition is not for all patients. Diagnosed with cancer at age 57, a fellow UCLA alum and research scientist—as well as Dr Kampe’s best friend—died a year later of myocarditis induced by treatment with a checkpoint inhibitor.

“This kind of outcome is extremely rare,” Dr Kampe pointed out, adding that 2% of patients or less have fatal outcomes from these treatments. Still, he said, it is important to acknowledge the potential disadvantages of immunotherapies. Among them are prohibitive cost, as well as sometimes serious and life-threatening adverse effects that include myocarditis, colitis, pneumonitis, hepatitis, encephalitis, hypophysitis, dermatitis, and arthritis.

Advantages include the great hope offered by immunotherapy, even in late-stage cancers. In addition, the treatments are easy to administer, generally well-tolerated, and because they’re not a poison, they don’t come with the same devastating side effects as chemotherapy and radiation, Dr Kampe explained. Perhaps most significant, immunotherapies have some oncologists using the word “cure.”

“Is this the holy grail of cancer treatment? Well, many cancer patients think so,” Dr Kampe said.

As evidence, Brianne Dart, a patient of Dr Kampe’s, 2-time survivor of metastatic melanoma, and mother of 4, shared her poignant story. At one time, she had 30 lesions throughout her body. She enrolled in a clinical trial and received nivolumab, a PD-1 immune checkpoint inhibitor.

“To this day, I’m just amazed at how these drugs work,” said Ms Dart, who is now cancer-free. “I’m just thrilled to be alive.”

As with any treatment, the risk-benefit ratio must be considered, but the zeal generated around immunotherapies is undeniable.

“As we see today, there are real, live people benefiting from this exciting therapy,” Dr Kampe said. “It’s an exciting time—for research scientists, for oncologists, but especially for our patients.”

Industry-Sponsored Sessions Pair AONN+ Meals with Helping of Treatment Information

It’s no secret that navigators are experts at multitasking. True to form, those in attendance at the conference are taking advantage of industry-sponsored sessions while enjoying AONN+ meals in an effort to explore cutting-edge innovations in oncology research and treatments while enjoying delicious culinary creations.

Peppered throughout the conference to accompany the breakfast, lunch, and dinner provided by AONN+, the sessions cover a wide array of topics and are hosted by pharmaceutical and biomedical representatives who share knowledge and insights to help navigators enhance patient care.

The sessions began Thursday as the conference kicked off, with a lunchtime presentation sponsored by Celgene entitled “Exploring Differences in Disease and Care for African Americans Living with Multiple Myeloma.” At dinnertime, Lilly Oncology welcomed attendees to its session, “A Treatment Option for Patients with HR+/HER2– Advanced or Metastatic Breast Cancer.”

Friday’s breakfast brought a session on NINLARO® (ixazomib), an oral treatment for multiple myeloma, presented by Takeda. Merck offered a lunch presentation, and dinner was accompanied by “Spotlight on Cancer Morbidities: Febrile Neutropenia and Bone Complications,” sponsored by Amgen.

Saturday promises an equally engrossing slate of sessions, with Takeda offering information on ALUNBRIG® (brigatinib) for advanced practice providers and nurses over breakfast; a lunch presentation on the management of patients with renal-cell carcinoma who are treated with CABOMETYX® (cabozantinib) by Exelixis; and a dinner presentation by Amgen titled “Understanding Early Molecular Diagnosis & Navigating Individualized Treatment for EGFR+ mNSCLC.”

AONN+ is truly grateful to the industry sponsors that are providing these valuable sessions to conference-goers, who benefited from the wealth of information shared within them.


Preliminary Results of National Navigation Metrics Study Offer Insights into Top Barriers

After the rigorous process of creating 35 evidence-based oncology navigation metrics to fill a void in measuring the quality of care delivery and the cost of delivering that care in navigation programs, the next logical step was to put those metrics to work. In partnership with the American Cancer Society and Chartis Oncology Solutions, AONN+ has done just that.

Conceived just over a year ago, the National Evidence-Based Oncology Navigation Metrics: Multisite Exploratory Study to Demonstrate Value and Sustainability of Navigation Programs is already providing insights into oncology navigation programs throughout the country. Members of the AONN+ Standardized Metrics Task Force—Danelle Johnston, MSN, RN, ONN-CG, OCN​, Chief Nursing Officer and Senior Director of Strategic Planning and Initiatives for The Lynx Group/AONN+, and Co-Principal Investigator for the study; Tricia Strusowski, MS, RN, Manager of Chartis Oncology Solutions; and Elaine Sein, BSN, RN—shed light on the metrics and shared some of the knowledge gleaned thus far from the first-of-its-kind pilot study during an enlightening session.

“We’re very excited about our study,” Ms Sein said, adding that they expect to be able to share additional preliminary results from the 6-month study at the AONN+ Midyear Conference, May 17-19, 2019, in San Diego.

As navigators are well aware, the value of navigation programs doesn’t always translate easily into dollars and cents the way some other programs do. In fact, in addition to wearing the many hats that come with the role, navigators also have to prove to administrators the value of all they do in their various institutions. Although data collection may seem like just another task added to the navigator’s already full plate, the benefits of the information gathered far outweigh the time spent doing it, Ms Johnston told attendees.

“I want to empower each one of you to take these metrics and implement them in your setting to demonstrate the value of the navigator role,” she said.

Explaining the shift in the healthcare landscape driven by the Triple Aim, the goal of which is to improve the patient experience of care, improve the health of populations, and reduce the per capita costs of medical care, the presenters elaborated on the role of the standardized metrics in meeting these goals. Measuring patient experience, clinical outcomes, and business performance or return on investment, the metrics close a gap in the literature on measuring navigation programs’ success. In addition, despite the diversity of navigation program structures, the metrics can be used in all settings to coordinate high-quality, team-based care and demonstrate the sustainability and value of these programs.

“We know we need to compare apples to apples,” Ms Sein said.

Using a rigorous tool to select from among more than 50 applicants, the researchers chose 8 study sites to participate. The sites are:

  • Abington-Jefferson Health, Asplundh Cancer Pavilion, Abington, PA
  • Centra Health, Alan B. Pearson Regional Cancer Center, Lynchburg, VA
  • MaineGeneral Health, Harold Alfond Center for Cancer Care, Augusta, ME
  • Medical University of South Carolina, Hollings Cancer Center, Charleston, SC
  • Rutgers Health, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 
  • Capital Health Cancer Center, Trenton, NJ
  • The University of Arizona Cancer Center, Phoenix, AZ
  • University of Colorado Health, Fort Collins, CO.

A number of the sites had representatives in attendance, and the presenters expressed their gratitude to them for taking on the work involved.

“Our outcomes that we get from this are going to be well worth all we’ve had to do,” Ms Sein said.

Providing a case study from among the participating study sites, the presenters highlighted The University of Arizona Cancer Center, which began collecting data at the beginning of 2017. The center’s top 2 barriers to care in 2017 were history of anxiety, depression, or a mental health diagnosis, and distress, both of which held true throughout all 4 quarters. Interestingly, in the first 2 quarters of 2018, anxiety, depression, or a mental health diagnosis remained the leading barrier for patients at the center, but activities of daily living replaced distress in the number 2 spot. Observing such trends and discerning solutions to overcome these barriers are among the study’s aims.

Through training and utilization of tools—soon to include use of the Chartis Oncology NAVmetrics, an iCloud-based business intelligence product—site visits, weekly calls, and data quality checks, the study sites are continuing to capture and report data from 10 of the standardized metrics. The addition of the NAVmetrics software will serve to enhance the usefulness and meaning of the amassed information.

“This is super simple and usable,” said Ms Strusowski, discussing the capabilities of NAVmetrics. “What I think is really cool is all the ways we’re going to be able to slice and dice all this information.”

Navigation program leadership at The University of Arizona Cancer Center is already seeing the value of the data collection, as well as the study as a whole.

“Tracking metrics has become a well-ingrained good habit, like hand washing,” said Beth High, Navigation Program Manager. “It’s something we do on a daily basis to support our ability to care for more patients in an evidence-based way.”

American Cancer Society’s Patient Navigator Tracks Delve into Issues Vital to Success of Navigation

With a finger on the pulse of navigation, the American Cancer Society (ACS) added 4 sessions to Friday’s agenda, with discussions of issues that included reducing disparities, cultural competency, caring for the caregiver, and building collaboration among members of the multidisciplinary team. Offering concrete solutions, these Patient Navigator Tracks prepared attendees to confront issues that arise in their day-to-day practice.

Collaboration is essential to providing high-quality care, but it’s not always as simple as it may sound. Although the value of the multidisciplinary team is well-known, defining and coordinating roles to collaborate smoothly with seamless handoff can be complicated.

In a discussion on building collaboration among the multidisciplinary team, a standing-room-only audience engaged with a panel focused on the optimal use of the various roles within an oncology navigation program, including social workers, administrators, and patient, clinical, and financial navigators, as well as how these providers can practice to the full scope of their licensure without duplicating services. Using concepts from Team-Based Oncology Care: The Pivotal Role of Oncology Navigation—a book written by navigators, for navigators—the presenters equipped attendees with practical solutions for harmonious and effective collaboration.

“I think you either get in line and get on the team, or you’re not a good navigator,” said Elizabeth Franklin, LGSW, ACSW, Executive Director of the Cancer Policy Institute at the Cancer Support Community and a member of the AONN+ Leadership Council. “It’s a team effort.”

As members of the packed house posed questions, the discussion touched on the navigator’s role. The panelists agreed that navigators should continually evaluate their role within the multidisciplinary team. Equally important, they said, is setting boundaries around what that role entails and what falls outside of it. Elizabeth Glidden, MPH, OPN-CG, also a member of the AONN+ Leadership Council, pointed out that it’s important not only to utilize the resources available on one’s team, but also to look outside at resources available in the community. This can help eliminate some time-consuming tasks navigators often shoulder, such as coordinating transportation for patients.

Fellow AONN+ Leadership Council member Sharon Gentry, RN, MSN, CBCN, CBEC, ONN-CG, agreed. “And if you find a good resource, share it,” she added.

Also part of defining one’s role is setting boundaries, according to Ms Franklin. Failing to do so can cause problems in the patient–navigator relationship and even cause liabilities, she said.

“There’s no code of ethics for patient navigators,” she said. “We really need to work on that.”

Regarding the role of metrics for navigation programs, Ms Franklin said although the value of these programs is clear, the need persists for navigators to prove their worth to administrators. “It’s really important to constantly build the case,” she said. “If you get thank you notes from patients, keep them and show them to administrators.”

Ms Gentry said the best way to approach measuring the value of navigation is to begin with the “low-hanging fruit” when it comes to metrics.

“Go with the easiest thing you can influence to make a difference,” she said.

Following this popular session, attendees could be heard singing its praises in the hall.

“That was amazing,” one of them said.

Another session was sponsored by Merck along with the ACS and gave a synopsis of the Care Coordination Navigation Program to Reduce Disparities in Cancer Care, a 4-year initiative currently underway at 6 pilot sites, thanks to a grant from the Merck Foundation. Designed as a quality enhancement tool for the ACS Patient Navigator Program, the program’s goal is to augment navigation services to reduce disparities with 2 additional components. The first is to promote patient activation and empowerment through coaching by navigators to manage and overcome barriers to care, and the second is to increase care coordination by fostering collaboration to provide a safety net to patients as they move through the cancer care continuum. The presenters shared preliminary results and lessons learned thus far.

Outlining techniques for facilitating communication and care across cultural boundaries, Tawana Thomas-Johnson, Vice President of Diversity and Inclusion at ACS, also described why it is crucial for navigators to become culturally competent in working with patients of diverse backgrounds and cultures.

“It’s really important for us to understand who our patient population is, and that it’s not our grandmama’s patient population—it’s a new day,” Ms Thomas-Johnson said. “It’s not turnkey, it’s not cookie cutter, it’s not one size fits all.”

Not only does cultural competence result in improved outcomes for patients, it also benefits institutions by decreasing costs and disparities in care, among numerous other social, health, and business benefits.

Gone is the once popular concept of a melting pot. The new paradigm is a salad bowl, Ms Thomas-Johnson asserted.

“We want each thing to maintain its flavor in our salad bowl,” she said, drawing an analogy to diverse patient populations.

Recognizing the importance of the caregiver role in oncology care, Rachel Cannady, Strategic Director of Cancer Caregiver Support for the ACS, presented “Caring for the Caregiver: How the American Cancer Society Meets the Needs of Family Caregivers.” Family caregivers shoulder physical, emotional, and financial demands that can become overwhelming.

“They’re left alone to figure out, ‘How do I help me?’ Caregivers are truly the ones that are trying to find the new normal in the situation after a cancer diagnosis,” Ms Cannady said.

According to research the ACS conducted on caregivers, their top 5 unmet needs are dealing with the patient’s distress, as well as their own, grappling with lifestyle changes, obtaining information about the patient’s cancer, and discussing the survivor’s concerns with him/her. By looking at these results and others, the ACS developed resources to address the needs of caregivers through its Caregiver Support Program, which Ms Cannady shared with the navigators in attendance. She encouraged them to make use of the resources available at cancer.org/caregiver.

“In order to care for the other person, they need to care for themselves,” she said.

Breakout Sessions Give Navigators Opportunity to Pursue Individual Areas of Focus

Those in the field of navigation share an abundance of commonalities, but myriad specialized areas of focus make each navigator unique. With this in mind, AONN+ provided 4 breakout sessions as part of Friday’s offerings, covering cancer in men, gynecologic oncology, pancreatic/gastrointestinal cancers, and the nutritional management of head and neck cancers.

“It’s Raining Men! All About Cancer Screening, Prevention and Management Strategies, and Counseling for Men,” presented by Frank dela Rama, RN, MS, AOCNS, AGN, BC, highlighted significant issues in men’s health as they relate to oncology.

“We often don’t take care of ourselves,” he said of men, adding that male patients must be taught to conduct testicular self-exams.

With a multitude of facts from the American Cancer Society and Movember Foundation, the session was an in-depth exploration that touched upon fertility concerns, symptoms of hormone deprivation, mental and emotional health, how men handle a cancer diagnosis, and issues specific to gay and bisexual men.

“Just as women are different from men, gay and bisexual men have different concerns,” Mr dela Rama explained.

A session on the nutritional management of head and neck cancers had registered dietitian Karen Godinez, CSO, imparting a thorough examination of the distinct needs of this patient population. A discussion of nutrition goals and nutrition-related side effects of treatment included considerations related to G-tube placement, management steps for the pretreatment and active treatment phases, and interventions for combating specific adverse effects. Underlining the critical role of food, not only for physiologic survival, but also its emotional significance, helped to drive home the connection between healthy nutrition and quality of life for patients with head and neck cancer.

Peg Rummel, RN, MHA, OCN, ONN-CG, joined Ms Godinez to discuss the role of the navigator in caring for these patients.

“One of the biggest challenges for head and neck patients is getting dental clearance before radiation treatments,” she said, adding that most patients don’t have dental insurance or a dental provider. “You just need to try to work the system. One of the things we need to do is advocate for these patients.”

Delving into the treatment and management of pancreatic/gastrointestinal cancers, Trish Gambino, MSN, RN, led attendees through the role of the navigator with this patient population, current and emerging treatments, resources specific to pancreatic/gastrointestinal cancers, and barriers navigators face with these patients.

“I try to engage the patient in their journey so they understand their disease,” she said. “I want them to know we want to do what’s best for them. It gives them some control back, too.”

“I Am Woman: GYN Oncology,” presented by Penny Daugherty, RN, MS, OCN, ONN-CG, was an informative commentary on gynecologic cancers, including ovarian, cervical, and uterine/endometrial, as well as human papillomavirus. Along with detailing each, the session provided insights on the management of women facing these cancers, as well as how to support and educate them along the trajectory of their disease.

“We have to support them wherever they are,” Ms Daugherty said. “They don’t think they have a future. My phrase I use with patients is, ‘This is doable. We can work with this, and I’m going to work with this. I’m going to be with you.’”

Also covering areas such as nutrition, supplements, spirituality, and sexuality, among others, Ms Daugherty empowered attendees with the knowledge needed to address all aspects of care for their women patients.

Product Theaters Feature Major Players in Oncology Treatment

Informative and engaging, product theaters are a chance for conference attendees to gain a comprehensive view of treatments at the forefront of oncology care. Hosted by industry sponsors, the focused sessions allow clinicians to glean information on products straight from their manufacturers.

On Friday afternoon, attendees had a choice of two 1-hour product theaters hosted by PUMA: a presentation on NERLYNX® (neratinib) for the treatment of early-stage, HER2-positive breast cancer and “Addressing the Unmet Need for Patients with Unresectable Stage III Non–Small-Cell Lung Cancer.”

Saturday afternoon will bring a second chance to attend one of these educational sessions. Genomic Health Oncotype DX will host “Tailoring Treatment for Early-Stage, ER-Positive, HER2-Negative Breast Cancer in the Era of Precision Medicine: A Nursing Perspective,” and Sirtex will offer “SIR-Spheres® Y-90 Resin Microspheres for the Treatment of Inoperable Metastatic Colorectal Liver Tumors.”

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Although the conference was winding down, Sunday was host to more events of interest for attendees. A session on genetics and genomics served as a primer for navigators, while breakout sessions gave attendees the opportunity to get hands-on experience with integrative therapies, including art therapy, aromatherapy, pet therapy, and healing touch. Popular and engaging, these sessions were a fun way to bring the weekend’s events to a close before bidding a fond farewell—until the Midyear Conference in May!

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