What You’ll Learn

An oncology nurse practitioner who specializes in breast cancer discusses advances in treatment through targeted therapies, challenges unique to rural patients, and why oncology can be a field of “creative medicine.” Inspired by patients, she describes the careful balance clinicians must find between giving cancer patients all the support they need but also “teaching patients that they are stronger than they think.”

Interviewee: I work with a cancer center that has about eight physicians currently and probably 10 nurse practitioners. The doctor I work with specifically, we are breast cancer specialists and we do see some lymphoma, malignant hematology. We have in our group we sub-specialize, most of the doctors are breast. We have some that are GI, some that are lung, but with a recent turnover in doctors, we’re all now taking care of everything. And we do have a lot of rural medicine. We have rural clinics in Gaffney, South Carolina, Union, South Carolina, and in those clinics we have to cover all the bases. But it’s great because it forces you to stay on top of things and learn more.

VIVO: What is the last time you were inspired by something? Maybe it’s medicine, maybe it’s a patient, maybe it’s your dog, whichever one it is. What’s the last time you thought, “Wow”?

Interviewee: That’s why I’m in the job I’m in is because it is so inspiring. People are like, “How can you do that? It’s so depressing.” And yes, on a daily basis, coming home you’re thinking, “I got this 40-year-old or this 20-year-old and they’re going through this, or have to go on hospice.” But these patients are so strong.

For me, I had a lady recently who she found out her cancer came back and now she is probably not going to have much time, but her son was getting married and setting goals and seeing how strong people are and willing to push and how kind they are. They’re even helping other cancer patients. I had a lady the other day who was going through her own struggle and she gave the lady in the waiting room her wig because that lady was struggling more. And just the hope and the sheer love that these patients share. That’s what keeps me coming back every day and that we can try and help them more and more through science. We’re slowly starting to have positive outcomes for some of these patients.

VIVO: Are there any surprises? You said that this is why you got into this field and the reasoning there, but once you got into it and once it started being your day-to-day, was there anything that shocked you maybe? Or was it what you expected?

Interviewee: I would say the only shocking factor would be the logistics, the insurance barriers and then the amount of information out there to learn and how do you make sure you’re treating these patients accurately. Because you got stuff coming in from drug reps and you have stuff coming in through your email, through whatever company you use to get your information from. So sorting through all that. Those two things I would say have been the biggest shock factors.

VIVO: Can you talk more about the advances, better outcomes and other things that you’re seeing and what those are result of?

Interviewee: I’m lucky because we deal with the breast cancer world and they have had tremendous advancements in their treatments as far as targetable therapies, not just immunotherapies, but things that targets breast specific cells, the CDK4/6 inhibitors. And for patients especially with metastatic breast cancer, they would come in and maybe live a couple years are living five, 10 even longer years. And I think all this stuff is a product of research, clinical trials, and we do have clinical trials at our facility. We’re opening two more on breast cancer, especially hormone positive breast cancer, which is 75% of our cases. And I think other areas like lung and colon, they’re seeing advancements too, in more targetable therapies. Looking at not only germline mutations but somatic mutations like the tumor versus what you carry down. And being able to look at those targets and find out how they can individualize cancer care, which is what you need to do because each tumor is so gnarly.

VIVO: That’s a good word for it. How do you get those results? How do you figure out the somatic mutations and things like that? What do you use?

Interviewee: We have a couple of different platforms and our facility isn’t super picky. Some doctors want to use the ones, some want to use others. So we have Guardant360. We use Caris for some of our profiling. We have a few in-house things we can do. With colon cancer, we use Signatera. With breast cancer, we do Oncotypes and MammaPrint. So there’s those companies that we get all that information from.

VIVO: And when you get that information, is it clear what you need to do after that as far as actionability or does it seem overwhelming sometimes? Because sometimes looking at genes and thinking, “I have 10 patients to see today and right now I’ve got this report,” what do you do with that and what’s the easiest way to synthesize that into reality?

Interviewee: I think most of us, most the doctors, providers will look at the results ahead of time before the patient comes in to see and try and already have in your mind what is a targetable mutation that you would want to treat that patient for. Because we know the drugs that line up with that and you know the patient’s performance status and what they’ve already had. So you want to know in your head what would I want to give them next line that they could tolerate and that might help them. So if you do that, it helps. Now sometimes there are results that come back and it’s like, “None of this makes sense.” And you sit down with the patient, and you go over it and even offer them going somewhere for a trial because that might be their best bet, but that’s how it goes.

VIVO: Do you see a difference because your practice is a little bit larger, do you see a difference in the older versus the younger oncologists with how they use that information? It’s so quickly moving, right? And it’s only been the last, what? 15 years. So a lot of doctors are coming into it now and it’s just part of… It’s like I would imagine the computer generation. There’s a whole set of people still who are like, “I can’t use a mouse.” And then there are other people who are coding. So is there that kind of difference with oncologists do you see, or do you see that they all keep up with the new things regularly?

Interviewee: I feel like they do a good job of keeping up. The two or three older ones will come to the younger ones and say, “Hey, this is the way we used to it. I have these things going on. What would you do in this situation?” And then we do the tumor boards for each individualized tumor type, so they can always present their case at that. But I think they’re doing well at learning that this is where things are going. I would say there might be one older doctor that wants to put everybody on hospice. So sometimes patients don’t end up going to him, but there’s always a role for that too.

VIVO: You spoke about the rural experience as well, so I’m interested in that. Do you see huge differences in maybe the staging or when they come in or how they come in or the way that their treatment goes? What’s the biggest change between suburban and urban patients and then rural?¬†

Interviewee: Yeah, from A to Z, the start-to-finish work, a lot of them have limited resources. They might not have a car or they don’t want to drive. And for us it sounds silly, but 30 minutes for them on the busiest interstate in the area is scary or they don’t want to do it. So that’s an issue. We used to have more access for them in their town. We had radiation facilities. We still have chemotherapy, so they’re still having to drive for that.

I would say there’s also a barrier and even education about why do I need this biopsy? They don’t understand how treatable things are. So sometimes you have to have that discussion that this isn’t a death sentence or that the biopsy itself is not going to harm you, that that’s part of the process. And we have nurse navigators that are excellent at working with our patients to get them. They’ll get gas cards so they can go to those radiation or biopsy appointments that are in Spartanburg itself and help them. We have cancer associations that provide other resources for supportive things through treatment like Ensure, Boost, wigs, even basic items, toiletry items. And I think while rural medicine can be challenging, it’s more rewarding because those patients are appreciative that you’re there in their area to help them.

VIVO: Do rural patients tend to wait longer? You’re saying 30 minutes down a highway, things like that. Do they tend to have more advanced disease? Do they tend to miss treatments? Do they tend to not want to do things because of not having transportation, et cetera? What kind of thing do you see there?

Interviewee: Yes, I would say they’re probably majority diagnosed at a later stage in those areas. Most of our other clinics, they’re diagnosed what stage one, stage two, and out that direction, it’s usually further along. Now they do miss appointments. Some of them have frequent blood work almost every week. And so getting them to that is mind-boggling. Trying to get the sometimes the families, you hate to say that getting the families involved, almost like if you’re at a transplant center and they require you to have a family member, you want to make sure they have a good family support or somebody that can bring them. And then if we can provide gas cards or public transportation. Chemotherapy, yeah they miss chemotherapy. And at that point you’re doing your best. You might not be on schedule, but you’re trying to get the most treatment in that you can get in before you get a scan or take them to surgery.

VIVO: Does that throw off the whole treatment schedule? Does it mess things up far as the chemicals in their bodies, things like that? Or is it something that can get back on track easier? 

Interviewee: Certainly any chemo, even if it’s curative or non-curative, if you don’t have that exact schedule, can have the potential to mess things up because the way they come up with the recipes for chemo is a trial and they found that that has the most cell kill by giving it every so often. In our patients that are curative, now they get pushed as hard as possible. And those patients are younger. And let’s say they are older and they’re curative and they’re missing their appointments, well then we say, “Is this for you? Are you okay with stopping and walking away and being done?” Now if they’re in a palliative setting where this is a marathon and not a sprint, and I’ve got a little colon cancer lady sometimes she’s like, “I didn’t feel good this week and I’m not coming for chemo.”

And I’m like, “But it’s working.” You try and see if you can lower the dose, reduce toxicities. Is it the toxicities that’s making them not show up for their appointments versus a true transportation issues? Sometimes it is. She has to wait on a ride from a grandchild. So all that plays into it. But if they’re not going to get their treatment on a timely fashion too, you can look at altering the schedule of the treatment or even the type. Are there pills where they don’t have to come in for infusions? So there are options there. It’s creative medicine.

VIVO: Going back to the general population. You talk about the targeted therapies and the somatic things, and what kind of testing do you do after treatment starts? Do you continue to test? I know that depends on the type of cancer, but for instance, with lung or breast specifically or maybe prostate, how do you continually keep a cadence of testing to make sure things are working?

Interviewee: So in certain, it depends on the type of the stage. I would say more so if you have an early stage breast cancer or lung cancer that’s cured and you go into a monitoring phase, you wouldn’t retest unless they had a true recurrence. And at recurrence, I think everybody’s decided now you should get tissue and retest and then definitely test the blood because you can have tumor mutations changes from the original even in a short course of a year if that happens.

Now, if you’re following somebody that is going to be treated long-term whether that’s maybe a cure or palliative, those treatment changes, let’s say we’ve got a lady with lung cancer, she’s on her fourth line treatment. She has had probably at least two of those Caris or Guardant tests along the way to make sure that we’re not missing anything new for her. And we did find a new medication that we’re giving her now chemotherapy, immunotherapy combination. So it’s a case-by-case basis, not a set every so many months or so many years, but based on you scan those types of patients pretty frequently three to six months. And then if they’re starting to progress, then you talk about do we need to do more testing at that point?

VIVO Strategist: Got you. And when you talk about Caris or Guardant do they do the same test? Is it the same thing, same results or are they different genes that they look for, et cetera?

Interviewee: They are different. The Guardant, we use the Guardant360 is the biggest one, it can also give us information. One gives us information on clinical trials that match that patient and specific… They both give you the mutations and the treatment recommendations or what would match up with that. But one gives you access to more clinical trials and things.

VIVO Strategist: And that’s useful to you as a clinician to be able to match things up?

Interviewee: It is very helpful, yes, because sometimes there’s patients that are interested in second opinions in clinical trials and it takes a lot to get on research.gov, look up all that stuff, figure out what would match me. But if this one is saying this matches what you have in your blood, you can call these people and they’ll call them and say, “Is this trial still available?” And sometimes it’s closed or they might have to move to… In Texas, San Antonio, there was one that was going on and she didn’t want to move, or some people do move. So it’s if you have a true concern, I think it’s a good option.

VIVO: Going back, I guess maybe more to the inspirational side, I know that your patients are varied. So I know it’s a broad question, but overall, when patients come in, you said that they’re so strong and so brave, what advice do you find yourself giving most of your patients? Is there something that you realize that needs to be said no matter what for a lot of patients? Is there an overarching, maybe a hopeful message or advice or something?

Interviewee: The biggest thing I’ve learned, and even though I’ve been doing oncology probably total 20 years, in the last two years, teaching patients that they are stronger than they think. And every time we see them we’re saying, “You’re doing a great job and keep up good work,” that encouragement because you couldn’t create a dependence on you from a patient where they think that they have all these fears and you feed into the fears.

I think with the dependency, you can create dependence on you. But you would rather them take the position of being in control of their healthcare because they’re already at a loss of control. They’re losing their hair and everything’s financially falling to crap and their health. So having some control with… This brought something to mind. We added in more classes at our facility, yoga classes, art classes, cooking classes, support groups to bring these people together. But that being said, telling them that we’re available to support them, you can call us 24/7, here’s our after hours number, here’s all the medications that you might need, but please don’t struggle at home. So being able to offer all that and then build them up that they can do this. It’s going to be tough. It might be the toughest year of your life, but we want you here for 30 more years, 40 more years is the thing that they get.

VIVO: What advice would you give to someone who is going into the medical field and maybe doesn’t… I find some people are like, “Oncology sounds good.” They’re not positive that oncology is their thing. What kind of advice would you give?

Interviewee: I would say, oncology is a long, hard learning curve. It is a minimum of six months to a year to even wrap your brain around all of the nuances of learning about blood counts and tumors and things. Then you have the large supportive factor. I’ve worked in the ER and you have patients there that are traumatically sick and you need to care for them, but it’s a bing bang, boom, move on situation. And while in oncology, you don’t want to become too attached. You don’t want them to become your best friend, but you have to build that trust relationship, talking with your doctor, where that they can feel confident in the care they’re getting and that you’re there to support them through that journey. And for a lot of patients, I think what you need to tell them or somebody that’s getting into this, you need to let them go at some point.

They don’t want to be lifelong cancer patients. We want you to return to a life. So it’s that process. And if you’re coming into oncology, I think you have to know that there’s going to be hard days. Patients don’t care about your hard days. That’s the other thing. You have to set aside your stuff. Although some patients are ridiculously sweet and ask about you all the time. So I think that’s harder than some of the other things where you come it’s more task oriented. If you’re working in a med surg unit or a cardiac cath unit, it might be more task oriented.

VIVO: You said that you worked with this doctor specifically, or right here focusing on breast for about two years?

Interviewee: Yes.

VIVO: That learning curve that you’re talking about, do you have to relearn treatment options and things like that? Or do you feel like you have a general idea across the board? Because like you said, cancer is so varied. What’s the learning curve there, changing from a general thing to a more specialized area?

Interviewee: Definitely still a curve. So a little background, when I started with oncology, I started with a GYN oncologist, so ovarian, cervical, vulvar cancers. And I worked with him for almost 12 years, and that’s when I went back and got my advanced practitioner license. So transitioning to breast, that doctor was like, “You need to find something and specialize in it.” And I was like, “Well, why would I do that? I’ve worked in the ER and I love working with everything.”

I like knowing a little bit about everything, but until you truly specialize, you don’t know all those nuances. And breast cancer was a hundred percent different than coming from GYN world. And I had a different physician that mentored me. He’s been there, he’s one of our older physicians, and talking about all the small details, pathology things, and then learning. I’m coming from a female to female thing, so GYN cancers or female, breast cancers are typically female. So that helped knowing that basis. They worked well together, but definitely something totally different. And now, like I said with this rural medicine, we’re learning so much more about lung cancer, and I’m like, “Wow, that’s a whole other bucket to dig into.”

Participant Profile

• Breast Cancer Specialist Nurse Practitioner
• Spartanburg, South Carolina
• 20 years in oncology (12 years in GYN oncology, 2 years specializing in breast cancer)
• Cancer center with 8 physicians and 10 nurse practitioners
• Primarily breast cancer and some malignant hematology
• Patient Demographics: Serves both suburban and rural populations across multiple clinics
• Key Challenges: Insurance barriers, rural patient access to care, transportation issues for patients
• Notable Priorities: Patient empowerment, comprehensive supportive care, staying current with rapid advances in oncology