What You’ll Learn¬†

An experienced oncology nurse practitioner reflects on the science and art of treating patients living with cancer, and provides insights on advances in targeted therapies, practicing in a rural region, why patients inspire her and the importance of forming a relationship with patients to guide them through the oncology journey.

Interviewee: I’m a nurse practitioner. I work in an outpatient hematology/oncology clinic in rural Nevada. We see a wide variety of patients. We don’t specialize in just one type of cancer, general oncology. So that can mean anything from breast cancer, colon cancer, to something like acute leukemia that we would send off to a tertiary center. So we are involved in the diagnosis, treatment of cancer, and the sequelae of the cancer treatments. That includes ordering labs, diagnostic imaging, those kinds of things.

VIVO: When was the last time you were inspired in healthcare or by something unrelated to your work?

Interviewee: It’s always patient inspired, right? That’s the driving force when people say, “Why on earth would you pick oncology?” Mostly because patients are always full of hope, and then there’s the acceptance of the disease, and then whatever the final outcome is, they do it with such dignity and grace. Throughout the entire process, they are so thankful for your assistance and guidance through the whole process. So it makes it a very unique specialty to be a part of.

VIVO: Is that why you became an oncology nurse? Did you originally go into oncology or did it find you?

Interviewee: It found me. I met it with much resistance. I didn’t want to have anything to do with chemotherapy, biologic agents. It was very intimidating, and then the opportunity presented itself in a package that you couldn’t throw away. It was no weekends, no holidays, 10-hour shifts, you’re done when you’re done, and then you get there and you meet these amazing people, and you start to research how the medications work. And the ultimate truth is, cancer in itself, if it wasn’t so devastating and destructive, is quite amazing. It’s this foreign thing in your body that is in an environment that’s trying to get rid of it and kill it, and yet it can survive and move and grow and supply its own food source and change its environment. It’s devastating, yet at the same time, an incredible anomaly that continues to elude us as clinicians.

VIVO: How long have you been working in oncology? 

Interviewee: Since 2007.

VIVO: In that time, have there been any major advancements in the way that it’s treated or the way that it’s tested, or otherwise changed the game?

Interviewee: Absolutely. Our ability to now do the neo-genomics testing, looking for any kind of mutation. And now that we have the immunotherapies, we can target so many different mutations. In the beginning immunotherapy had a lot of potential, but they couldn’t tie it to everything. In the beginning we saw a lot of melanoma, lung cancers, and you almost forgot what it was like pre-immunotherapy.

You would have someone who was diagnosed with stage four lung cancer that was with us for maybe two years, and then after that you were seeing five years. And at the same time, you’re also seeing the side effects of the immunotherapy and trying to figure out what to do with that because we now have some longevity out of our patients, but we want to see quality. And now it has intersected every single kind of cancer that we’re treating. So that in itself is incredible.

VIVO: With those targeted therapies, what do you use to identify those alterations and mutations and things? Do you have a specific test?

Interviewee: We call it the Next Gen, which checks for all of those point mutations, translocations, particular proteins that we can go after. So that has been very exciting. The choice of test is hospital driven, so whoever they’re contracted with. The lab handles all of that.¬†

VIVO: What’s the biggest challenge in oncology?

Interviewee: Probably the clinical aspects. You can have someone who looks on the outside that they’re doing well and that they’re tolerating treatment, yet all of their lab and imaging is demonstrating that we’re not making any progress. Things are not growing out of control, but they’re also not getting any better. And when you’re fourth, fifth line, there’s only so many times you can do another biopsy, try to look for the same mutations, and hope that something else is opening up down the line.

So there’s a lot of difficulty in telling somebody. And it does happen a lot, in 2024, saying, “We don’t know,” that it’s odd to find yourself giving that as an answer, but you have to be truthful. And at that point you’re referring out to tertiary centers that might have something else to offer, because tertiary centers can get those kinds of things. That’s the other challenge. You see something that might be there, but insurance isn’t going to approve it because it’s not mainstream yet.

VIVO: How do you explain that to patients when the progression and therapy doesn’t match up?

Interviewee: You are as genuine and honest as you can be. I think the hard part is reinforcing, and I feel like it’s sensitive. When you have stage four cancer, you go in with the knowledge that most of the time it is incurable. Probably a good 95% of the time. And so you have to reinforce through the entire treatment that the goal is for extending life and hopefully including quality in that, and I think that’s an important part through the process, letting them know that at any time, when quality starts to suffer, that we try to navigate this process together. Of course, the patient is the ultimate decision maker, we are giving them the best options for them to make the best decision. And sometimes we can do that collaboratively where they say, “It’s in your hands,” or as a patient who brings in their daughter and their wife, we try to make that decision collaboratively. So I think that’s been the most positive way to have that discussion.

VIVO: Is there anything in oncology in general that you feel isn’t being said, isn’t being studied, or isn’t being moved forward on?¬†

Interviewee: If I had to say so, I would… And I don’t want to throw insurance companies under the bus, but that always seems to be a hindrance, especially with the introduction of immunotherapies. They are so expensive, and occasionally diagnosis… looking where they are as far as staging, the fact that they have so much of a say in whether or not the prescribed treatment is going to be authorized, most of the time, though, I want to say if you can do a peer-to-peer, it’s with another clinician. And those things are accepted. It’s the wait time. Of course, time is of the essence, especially when you’re first diagnosed.

Other than that, I’m not sure. You are sometimes so excited and surprised when something opens up, say, in February, and you have a patient that comes in in April, and they’re eligible for this new first line treatment for a metastatic disease. You can’t help but share with them, “Oh my goodness, there’s never a good time to have recurrent cancer, yet we had something that opened up that is very promising.”

I can’t say that on the medical end, I’m frustrated by anything, because at this point, the fact that we have third, fourth, fifth line treatment… In multiple myeloma, we have 13 lines of treatment. So it’s a positive time where you’re not at this moment putting your hands together in a praying motion saying, “We’ve tried everything, and aside from going to a tertiary center or starting to talk to palliative care, we’re not sure how to treat you.” I don’t find that I’m seeing that I did 10 years ago.

VIVO: Is there any advice that you find yourself giving to patients as a whole? One specific thing that you wish you could tell every patient when they come in?

Interviewee: Everyone is unique. Because you’re not having these side effects doesn’t mean that it’s not working, or because you’re having these side effects specifically, I’ll say, “Give us a chance. Give us a chance to help you over that hump. It might take more than a couple of cycles for us to figure out why the nausea and vomiting won’t go away, but if you work with us, if you communicate with us on a regular basis, we can work on that collaboratively.” But everyone is unique and, fortunately and unfortunately, our world is much smaller because of the internet, social media. So sometimes the access to somebody who has your same disease process, who is being treated at MD Anderson or in New York in another rural hospital doesn’t have the same experience you have, it can be discouraging.

So be a little bit more discerning where you get your information, and then if there is something that bothers you, please don’t go to Dr. Google to figure it out. Come to us. Bring those questions to us. Of course, I have been treating patients for 17 years, but I have never had the unique experience of being a patient. That puts you in a completely different group that you didn’t ask to be a part of. But it makes you unique in a sense of how you can also disseminate information. I can tell you this causes blah, blah, blah, but I don’t go home and have these symptoms. So use the network that you have, but also communicate openly with us so we can talk ourselves through that. So that you can be the most successful that you can.

VIVO: What would you say to someone who’s coming into the oncology space in general as a healthcare professional? What would be your one piece of advice or encouragement that maybe you, 20 years ago, needed?¬†

Interviewee: I’m in a unique position that I was an outpatient infusion oncology nurse prior to becoming a nurse practitioner. And so it’s unique because on the nursing end, when you’re doing the treatments and you’re seeing somebody who’s having more of a difficult time and their staging doesn’t allude to, say, a positive outcome, generally, you have more of the conversation of, “Is this something that you want to do? What are the pros, what are the cons?” But now being in more of the clinician setting, give it more of a chance. Let’s see, after three cycles, what the response is. It may be difficult now, but if we can get things to settle down, maybe we have more ammunition to fight this terrible disease, but you have to give it a try.

It’s hard to say. It’s all a unique perspective, how the patient looks, how they’re doing. Age is always a driving factor, and then whether or not they have comorbidities. But on the nursing end, the hand-holding that’s the best thing for you versus the clinician where you’re seeing that imaging, “Things are looking so much better. If you can keep going a little bit more, maybe we can get you the result that we’re looking for.” So trying to balance the two is difficult, but that’s why forming the relationship with your patient is so important that you can have those honest conversations or know how much to cheerlead versus pulling back.

VIVO: What are the biggest differences of working in a rural setting? 

Interviewee: A good example of that is treating… It’s more hematology, but still is oncology, treating someone who has acute leukemia who isn’t a candidate for transplant, which is the only cure that we have. So doing more of a conservative treatment, hoping to give the patient some longevity. But the side effects, a lot of those medications are things like anemia, having low blood counts or thrombocytopenia, having low platelet counts, and being in a rural area with limited access to, say, an infusion center and maybe an emergency room that they’re not as familiar with these kinds of cases. Sometimes we might not have the platelets on hand 24/7. So telling them that, “I know this is your hospital. I know this is where you’re familiar, but I’m going to need to ask you to go another 30 minutes to where they have platelets or maybe they can assist in a higher level of care now.”

And we see that a lot. Patients don’t want to leave their home. They have family here. They have animals, ranches, where they can’t leave, and they know what the outcome’s going to be, and yet trying to give them the best care that we can when we’re not as accessible. Having a clinic that’s only open from seven to five, or not having the medications or blood products on hand and having to ask them to go elsewhere, and maybe it might not happen. That’s not the word I’m looking for, but you’re symptomatic between the hours of seven and five until you’re not. There’s the weekend that you can’t get your nose to stop bleeding, and for them, it’s, “I know she told me to go here, but maybe they still can treat me here,” and now you’re being taken to another center in an ambulance.

VIVO: Can it be difficult to get the patients there for treatment? Do logistics keep people away?

Interviewee: Very rarely. It almost seems like once a diagnosis like this happens, people all of a sudden come out of the woodwork, “Let me help you. What can I do?” But in a rural area, we do have things like county transport that you can navigate. However, if for some reason you can’t get treatment that day and it would be more conducive to care to come back two days later, logistically that can’t happen because you have to give that public transportation a week. But it’s rare, which speaks a lot to the community in a rural center that so many people…

I’ve had other patients saying, “I’ll go get that other patient and bring them in.” Because I haven’t seen it doesn’t mean that it’s not an issue. I think that the potential for that, as a rural hospital, I’m surprised that we have as many patients as we do because our resources aren’t limited as far as getting medications and having access to all the data resources that we need to treat the patients correctly. But you wouldn’t think in such a rural area we’d have, say, the hundreds of patients that we do. So it is unique that we don’t have, I wouldn’t say that problem that you’re talking logistically about getting them to the center and getting them treated.

VIVO: Is any specific cancer at the top of your mind right now? Anything you’ve seen lately that’s, “Wow, we are moving forward here”?

Interviewee: I would have to say our Hodgkin and non-Hodgkin lymphomas. At stage four even, where people have bulky disease, it involves some of our organs, not the lymph nodes, we’re seeing tremendous results after three cycles. We have almost, cure. It’s amazing to see somebody so ill, and after one cycle, even noticing some other bulky disease resolve. And then by cycle three, you’re able to tell them, “Wow. By visualization of PET scan, you are in a complete and total remission.” That always blows my mind.

VIVO: Where do you see things in 10 years? 

Interviewee: Unfortunately, I would hope if there was, and this is out in left field, that if there was a cure floating around out there, some people talk about that it would’ve come to light, that watching people go through this process, I can’t imagine if there was something out there anybody would be able to, in good conscience go, “Well, we’re making too much money.” So with that said, in my mind, I’m not sure that that’s something that’s ever going to be achievable, going back to the whole uniqueness of cancer itself. So maybe in 10 years it can be more of a chronic disease like we’re seeing in diabetes, where you’re never going to be off diabetes island, but we have it so controlled that you have all the resources to live there happily for an unspecified amount of time.

So that’s where I’m hoping those things can go, and maybe even more in an oral direction so that patients aren’t having to come in. Even once a month has got to be a little bit daunting for any patient. Maybe, “Oh, great. I’ve got four weeks off,” but at two weeks you’re, “I got to go back,” and at one week it’s next week, and then the day before, “Do I still want to do this?” So maybe if we can go to more of an oral form, that would be more doable for our patients. Something that I’m living with that’s not as inconvenient as it was 10 years ago.

Participant Profile

• Female, Nurse Practitioner in Hematology/Oncology
• Location: Gardnerville, Rural Nevada
• 22 years of nursing experience, 17 years in oncology (since 2007)
• Practice setting: Outpatient hematology/oncology clinic within hospital system
• Focus: General oncology across various cancer types
• Patient demographics: Hundreds of patients from rural communities
• Key challenges: Insurance approvals for new treatments, limited resources in rural settings, and managing expectations of treatment outcomes