ASCO 2012: Advanced Practice Provider Seminar

One of the physicians at our practice received an email notice about something new at ASCO, its first ever pre-meeting seminar for advance practice providers. The stand-alone seminar was focused on the educational needs of advance practice in oncology. This seminar was cosponsored by the Association of Physician Assistants in Oncology and the Oncology Nursing Society. It was held from Thursday afternoon through noon on Friday.

The three nurse practioners (NPs) in our office managed to get away for two days to attend. From my estimate, it appeared that over 100 professionals were in attendance. The sessions focused on progress in breast, colon, lung, and prostate cancers, as well as targeted therapies and hematologic malignancies such as multiple myeloma, acute myeloid leukemia, and myelodysplastic syndrome. In addition, there was a session on specific communication techniques for difficult conversations.

I noticed a theme in most of the sessions: We are no longer only focusing on organ-based treatment. A lot of discussion was about the pathways. Meaning, if we can discover the mode of action and/or biological target in how malignancies work then we can continue to develop drugs to undo this specific action.

One of the first drugs to do this was a tyrosine kinase inhibitor called imatinib (Gleevec) for chronic myelogenous leukemia. It works by inhibiting the Philadelphia chromosomal tyrosine kinase and myeloid leukemic cell proliferation resulting in apoptosis.

Another key point was the importance of clinical trials, now more than ever because the future will involve more molecularly targeted therapies. More clinical trials are involving multiple drug regimens or using drugs previously used only in palliative or adjuvant settings earlier in the malignant phase.

So much information was shared in just two half-day sessions. It would be too cumbersome for me to list all of the information. The following are some of the highlights:

Coding and reimbursement

• The recovery audit contractors (RAC) list on their website the focus of their audits.
• Switching to ICD-10 from ICD-9 codes is now delayed and will be required in 2014. That will take us from 13,000 code sets to over 68,000 code sets broken down by speciality.
• Medicare.gov offers a coding tutorial on their website for PAs and NPs.

• Several clinical trials in play using only biologics for treatment (no traditional systemic chemotherapies).
• Many mutations (not just one) may make up the characteristics of triple-negative breast cancer.

• Earlier detection and better/new drugs for treatment have resulted in a decrease in mortality of over 25 percent in the past decade.
• Androgen-receptors are amplified in over 30 percent of all tumors found in castrate-resistant prostate cancer. More research to focus on this specific activity to develop new, targeted therapies.
• Radium 223 treatment specifically targets bone metastasis as does denosumab (Prolia/Xgeva).

• Per the United States Prevention and Screening Task Force (USPSTF), colonoscopy screening is recommended for those 50 to 75 years of age (with some exceptions depending on family history and other factors).
• Oxaliplatin (Eloxatin) may not make as much difference in the adjuvant setting as it does in the palliative care setting, more research is ongoing.
• In K-RAS wild-type colon cancers, cetuximab (Erbitux) has shown an increase in overall survival by five months.
• The "-mab" (monoclonial antibody) medications have the following breakdown in their names to determine their mode of action and how they were created.
• Mode of action: tu = tumor directed; li = immune-directed; ci = cardiovascular directed; vi = virus directed.
• How they were discovered/created: mo = mouse; xi = chimeric; zu = humanized; mu = human.
• An example: ipilimumab (ipi-li-mu-mab) meaning this drug (also known as Yervoy) has immune-directed action and was discovered/created from human elements.

• Compassion fatigue programs are growing in demand and in creation across the US in oncology settings for healthcare providers.
• Tools for communicating during difficult situations available for free at MD Anderson Cancer Center's Interpersonal Communication And Relationship Enhancement: I*CARE.

• Using grading for side effects is vital for consistency of evaluation, monitoring, and treatment. Especially when a patient is seen by multiple providers within the same clinic. Using the NCI-CTCAE version 4.03 grading tool is common practice by most oncology providers. A PDF can be downloaded for free from the NIH at Common Terminology Criteria for Adverse Events (CTCAE).
• Gabapentin in some recent studies has been shown to help with pruritus when antihistamines alone do not help enough.

• This 100-year-old disease is now looking at cytogenetic abnormalities and molecular attributes to determine best treatment options.
• AML makes up 90 percent of all acute leukemias.
• Overall survival is improved if the person’s age is younger than 56 years of age, and the worst (less than 5 percent survival) in those over the age of 65 years.
• Molecular markers are being discovered to determine good or not-so-good prognoses.
• Cytogenetics are being identified in patients who may or may not benefit from a transplant.
• Monitoring LDH level in AML patients during treatment is vital: An increase can also increase treatment-related mortality in those older than 60 years of age and increase in LDH is also associated in a decrease in clinical response.

Reference:
ASCO 2012 Clinical Care in Oncology for the Advanced Practice Provider Seminar, Chicago, IL in session from Thursday, May 31, 2012 through Friday, June 1, 2012.