Introduction to oncology
Cancer remains a leading cause of death in the United States despite a steady decline in overall cancer mortality from 1999 to 2016. This downward trend in mortality is likely because of improvements in early detection and dramatic advances in our understanding of cancer pathobiology. These advances have fueled the unprecedented development of novel immunotherapies and targeted pharmacotherapeutic agents; however, traditional cytotoxic chemotherapeutic agents continue to be the foundation of current therapy. The advances in knowledge and growing number of therapeutic options has changed the natural history of many common malignancies; however, the complexity of cancer care has increased in parallel. The complexity of care, along with the predicted shortfall of medical oncologists, has paved the way for the increased use of physician assistants (PAs) in the interprofessional oncology team, as evidenced by the increasing numbers of PAs practicing in the field. , This demand for PAs in oncology also presents an opportunity for PA students to gain oncology experience through elective clinical rotations. Despite the growth of professional opportunities in oncology for the graduate PA, elective clinical rotations remain underutilized by PA students. The goal of this chapter is to provide an overview of the practice of clinical oncology from the PA perspective and to present the challenges and opportunities available to the clinical year PA student.
Approach to the oncology patient
Patients typically are referred for oncology consultation upon receiving a diagnosis or presumptive diagnosis of cancer. The initial encounter in medical oncology is often preceded by a number of preliminary steps, such as arranging for medical records, pathology samples, and imaging to be sent to the practice in preparation for the oncology team evaluation. Under ideal circumstances these additional evaluations would take place before the initial oncology consultation with the patient. This initial oncology consultation invokes a considerable range of emotions in the patient, including, fear, anxiety, denial, and anger. It is important for the clinician to understand this in advance to work on establishing a comfortable and safe environment for the patient.
At the first visit the patient will undergo a comprehensive evaluation including a complete medical history. The medical history will provide information essential to understanding the many factors affecting the malignant process, the overall health of the patient, and potential therapeutic contraindications. If, for instance, the patient seeks treatment for recently diagnosed malignant melanoma, the medical history will focus on risk factor identification, with an emphasis on the social history, looking to identify significant ultraviolet radiation exposure, sunburns, and the use of tanning beds. Additionally, the clinical team will seek information on the patient’s medical history, including any personal or family history of cancer. Finally, a complete review of systems will seek to identify any additional symptoms of concern. When applicable, as in the case of a second opinion, the oncology clinical team will also seek specifics about previous cancer treatments.
The initial physical examination will address the systems directly affected by the malignancy, areas of concern identified in the review of systems, and a general assessment of the major organ systems. The patient may undergo completion of the formal staging process, which may involve a variety of imaging studies, serologic and tissue analysis for genetic markers, immunologic properties, molecular therapeutic targets, and tumor markers. The patient may also be referred for additional consultation with other medical specialists, including surgical oncology, radiation oncology, genetic counseling, and palliative care. For example, the patient with newly identified colorectal cancer may require surgery as the initial treatment modality, and this patient and family may also benefit from genetic evaluation for possible familial colon cancer syndromes.
Upon completion of the comprehensive medical history, physical examination, and review of the staging, the clinical team will present the patient with the results of the evaluation and with information on the stage of the cancer. The discussion will then shift to setting the goals for treatment and establishing prognosis and survival estimates. The goals of therapy are numerous and may include identification of the best regimen for cure, local disease control, treatment of metastases, or palliation of symptoms. Many factors will impact the treatment options available for the patient: tumor characteristics, the stage of the cancer, patient performance status, and a desire for aggressive treatment versus maintenance of quality of life. Based on the goals for therapy the clinician will provide the patient with information on the risks/benefits/outcomes expected for each therapeutic approach. Ultimately the patient, in collaboration with the oncology clinician, will select the approach that best aligns with his or her goals.
The oncology clinical team will develop the management plan and make arrangements for the medical treatment. There are many approaches to cancer therapy: inpatient and outpatient, intravenous and oral therapies. These medications may be given in combination via traditional chemotherapy cycles or the treatment may be ongoing. Typically, the treatment-related care will be managed by the oncologist or the oncology PA. Ongoing patient monitoring serves to promote patient wellness, manage symptoms of the disease or the treatment, identify adverse treatment effects, and recognize the possibility of disease progression. These regular evaluations may lead to treatment adjustments or temporary cessation, or discontinuation of therapy.
A typical day in oncology
PAs are important members of the interprofessional oncology care team; however, there is a paucity of data on the numbers of PAs practicing in the specialty, as this level of detail was not captured on our recent national surveys. In 2018 an extensive analysis of Advance Practice Provider data determined that approximately 1796 PAs provided oncology care in the United States. This figure was comparable to estimates derived from previous American Academy of Physician Assistants (AAPA) employment surveys.
PAs deliver oncology care in a variety of practice settings; however, the overall delivery of oncology continues to shift from private practice to the consolidation of practices or toward more hospital-based delivery models. PAs typically practice as part of an interprofessional team consisting of physicians, PAs, advanced practice nurses (APNs), registered nurses (RNs), clinical pharmacists, mental health professionals, and social workers. The role of the PA will vary based on individual state practice acts, collaborative agreements, provider expertise, and hospital privileges and policies. Oncology PAs may work in a generalist role in which care is provided to patients across varying types of cancer. At comprehensive cancer centers, however, PAs typically work within a section or division specific to the cancer treatment of one organ system; some examples include breast cancer, genitourinary, lymphoma, and neuro-oncology. Regardless of the practice setting or specific area of specialty, PAs report that approximately 80% of their time is dedicated to direct patient care, with the four most commonly reported activities being patient counseling, prescribing medications, treatment management, and follow-up visits. PAs also commonly conduct inpatient rounds, perform procedures, and participate in the evaluation of new patients. PAs in oncology typically report high rates of career satisfaction. , , The satisfaction likely stems from a number of factors, such as intellectual challenge, variety in clinical responsibilities, and the establishment long-term patient relationships.
Expectations of physician assistant students on oncology electives
An elective clinical rotation in oncology is an exciting and challenging endeavor for the PA student. Typically, the student is required to have completed an internal medicine rotation as a prerequisite for the oncology experience. Given the complexities of cancer pathobiology and the wide variety of organ systems involved, it is best to undertake this elective rotation in the later months of the clinical year. The expectations of the PA student entering the rotation will in part depend on the setting in which the student is placed, be it a private or community practice versus that of a comprehensive cancer center. The community oncology practice experience will typically have the PA student paired with physicians and PAs who work with patients undergoing evaluation and treatment for a wide range of malignancies. The student will see a mix of patients throughout the day, and the clinical care may involve inpatient and outpatient encounters. The clinical experience within a comprehensive cancer center will likely consist of a rotation schedule where the student will spend blocks of time within organ system or disease specific clinical sessions. In this situation the student will essentially be immersed in the care of individual cancer types, such as breast cancer, gastrointestinal (GI) oncology, lung cancer, and genitourinary cancers. Both the private/community practice and comprehensive cancer center will provide a rich experience for the student interested in oncology.
The student will likely undergo a period of orientation to gain an understanding of the specific oncology clinical environment. The clinical staff will expect the student to demonstrate a general understanding of the approach to the oncology patient. The student should arrive with a baseline level of clinical knowledge with regard to the most common malignancies, and a general understanding of the concepts of cancer staging, such as the tumor, node, metastasis (TNM) staging system; however, the student should be aware of some of the specialized cancer staging systems currently in use. The student should expect to spend some time shadowing, especially with new patient consultations or with rare and unusual presentations. These experiences will provide the PA student with insights into the evaluation and staging processes for individuals with a new diagnosis of cancer. As the clinical experience progresses the student will likely be encouraged to gather medical histories and complete physical examinations on patients presenting for treatment or those returning for monitoring or surveillance visits.
In addition to the general practice of medical oncology, the student may have the opportunity to gain experience in palliative care, interventional oncology, and radiation oncology. With a well-crafted clinical rotation experience, the student will gain insight into the unique intellectual challenges that arise within the specialty of oncology.
Typical settings for oncology
Although each oncology practice will be organized according to its size and mission, most cancer care takes place in various clinical settings. Students will typically have the opportunity to work in an outpatient clinic, an inpatient oncology unit, an infusion therapy center (which may or may not be affiliated with a hospital), a radiation oncology suite, a surgical oncology clinic, or the operating room (OR). In addition, an oncology rotation may include the experience of working with an inpatient palliative care service and hospice providers in the inpatient and/or home setting. Some oncology practices see cancer survivors in a specialized survivorship clinic that may be in a location different from the treatment clinic.
It is a truism in many aspects of medical practice, but particularly so in oncology, that it takes a village to care for a patient. Just as cancer treatment is multidimensional, so is its delivery. Most cancer patients receive more than one type of treatment (surgery, chemotherapy, radiation therapy) and the diagnosis of cancer itself requires expertise in specialized disciplines, such as pathology and radiology. This interdisciplinary care is the hallmark of oncologic practice and provides the PA student with the opportunity to learn from experts in various disciplines and to see how these individuals work together. Careful documentation and timely efficient communication are key to optimal oncology care, and students will be a part of this process as members of the team.
Important roles in cancer care begin with the medical oncologist—a physician specializing in the treatment of patients with cancer. The oncologist typically receives the referral of a patient newly diagnosed with cancer, develops the overall plan of care in collaboration with the patient, and manages the systemic pharmacotherapeutics of a patient while addressing any adverse effects of treatment. The medical oncology team will likely include PAs, nurse practitioners (NPs), RNs and clinical nurse specialists (CNS; including those specially trained to deliver chemotherapy), specialized pharmacists, social workers, and financial counselors.
The surgical oncologist is a surgeon specializing in the treatment of cancer who performs the operations necessary for care. For example, a cardiothoracic surgeon may develop an expertise in the excision of lung cancer or a general surgeon may specialize in the resection of colon cancer. The surgical oncology team often includes PAs (both in the OR and the clinic), NPs, surgical nurses and surgical technicians.
Radiation oncology is a unique field of medicine that works almost exclusively with cancer patients. Radiation oncologists are the physicians who lead the team in delivering radiation therapy designed to treat solid tumors. For example, a patient may receive radiation therapy to the site of breast cancer that has spread to a rib. The radiation therapy team will also include individuals who are not physicians but who have specific expertise in the planning and delivery of the radiation doses as well as the safe operation of the machinery ( Fig. 31.1 ). These include the radiation physicist and the dosimetrist. Advanced practice providers, nurses and radiation technicians will also be members of this team.