How APPs can be involved with genitourinary cancer care

Urology is a specialty with long-documented workforce shortages, making advanced practice providers (APPs) particularly beneficial for assisting urologists in seeing patients, obtaining histories, and even providing BCG instillations for patients with cancer. In this interview, Meredith E. Donahue, APRN-BC, shares how her career path brought her to urology, the numerous ways she supports a urology department, and how others may pursue a similar professional focus. Donahue is an advanced practice registered nurse in the Department of Urology at Vanderbilt University, Nashville, Tennessee. She was interviewed by Urologists in Cancer Care™ Editor-in-Chief Raoul S. Concepcion, MD, FACS, director of the Comprehensive Prostate Center and clinical associate professor of urology at Vanderbilt University School of Medicine.

Q: Please explain how you ended up in urology. Did you receive specialized training after obtaining your master of science in nursing?

A: After graduating from Furman University [in Greenville, South Carolina], with a bachelor’s in science, I was open to any job options when I landed at Urology Associates in Nashville, Tennessee. After my initial exposure to urology, I realized this is where I wanted to spend the rest of my career practicing.

When I started my master’s, I tried my best to experience every part of medicine but ultimately found myself coming back to urology, and specifically urologic oncology. When it came time to figure out next steps and what to do with a master’s, it was obvious that a urology nurse practitioner (NP) fellowship was the best next step for me. Fortunately, I was accepted to Vanderbilt University Medical Center’s Department of Urology NP Fellowship, where I was able to receive a year of specialized training in urology.

There are multiple ways to become an APP. For NPs, one must have a bachelor’s in nursing or any bachelor of science [degree], a registered nurse license, and complete a master of science in nursing. For physician assistants (PAs), one completes a bachelor’s degree in any field and then completes a master’s program. Both tracks prepare students to [work with] patients as generalists but offer little to no specialty training unless sought out by the student. Thus, making the transition into a specialty like urology may be quite difficult.

That’s where APP fellowships have proved to be pivotal in training APPs in specialty practice to be confident and independent providers. There are only a handful of urology APP fellowships across the country, so it is not reasonable to think all APPs can be trained in that way. It is important to provide adequate onboarding and education for APPs starting a new position in a specialty. With that said, it is exciting to be a part of this growing field of urology APP fellowships.

My now-colleague Gilbert Comola [ANP, CURN], who also completed an APP fellowship in urology, is the director of the fellowship and worked with the Office of Advanced Practice to develop a comprehensive training program in urology that includes spending time with each subspecialty of urology in the outpatient setting and in the operating room, as well as providing inpatient care to primary urology patients and consults. In the fellowship, I was also given dedicated time with our physicians to learn how to perform cystoscopies. With this skill, I can perform hematuria evaluations and stent pulls, or [can] address acute concerns that may require Foley [catheter] placement under cystoscopic guidance. In the fellowship, I had required didactic work as well as attendance at weekly conferences and lectures. This correlated with what I was learning clinically and has kept me eager to continue attending these educational opportunities beyond the fellowship.

Q: What is your current position in the Department of Urology at the Vanderbilt University School of Medicine?

A: I am a nurse practitioner in the Department of Urology and more specifically with our oncology team. I primarily support Joseph Smith, MD, and David Penson, MD. I have my own template every day, but when Dr Smith and Dr Penson are in clinic, I help support them by seeing patients and obtaining new patient histories, and by keeping the patient flow moving. I am also fortunate to share patients with all our urologic oncology [physicians]: Sam Chang, MD; Amy Luckenbaugh, MD; Dan Barocas, MD; and Kelvin Moses, MD. I am lucky to work with all these physicians because I can continue to learn from each of them in different ways.

My current position is all outpatient, working 5 days a week with 1 administrative day. Typically, I spend this time catching up on notes, fielding the urgent/emergent calls for my patients and my MDs, following up on results, and performing peer-to-peer consults. At this point, APPs in our clinic do not take any call.

Q: What are your daily clinical responsibilities as they relate
to patients with genitourinary (GU) cancer?

A: Most of my days are seeing new, return, and postoperative patients. These visits are interspersed along with following up on labs, imaging, and managing urgent and emergent calls from my patients and the patients of the physicians I primarily work with. I also spend half a day seeing patients in our advanced prostate cancer clinic with Dr Moses as well as half a day running our BCG clinic, instilling different intravesical therapies.

Q: What challenges has the COVID-19 pandemic lockdown created in helping your patients with cancer, and how have you overcome these?

A: At the start of the pandemic, the most difficult part was patients asking us whether they were at higher risk by coming to Vanderbilt versus higher risk by delaying surveillance imaging, treatments, or addressing onset signs/symptoms. At the beginning, we didn’t have answers to these questions; I don’t think anyone did. Fortunately, our team quickly learned how to adjust and appropriately guide our patients to keep them safe during the pandemic but also safely and appropriately manage their GU malignancy. Of course, this wasn’t easy. This required our team and me to learn and stay up-to-date on all the ever-changing COVID-19 data.

For every challenge during this time, I like to find the silver linings. During this pandemic, I have found patients to be more open to discuss how they are feeling physically, emotionally, and mentally about their health and diagnosis. In my (biased) opinion, [receiving a diagnosis of] a GU malignancy is one of the most vulnerable diagnoses a patient can encounter. It’s always a special moment when I see that wall come down, that wall of fear and embarrassment about having to discuss not only a malignancy but also parts of their body they may have never talked about before. I think this pandemic has shown patients and even our society that it is OK to talk with health care providers about how you are feeling both physically and emotionally. It is exciting to see this shift and it is a reminder that cancer is not just a diagnosis of their physical body but also of the patient’s mental and emotional health.

Q: Can you think of situations in which, because of your training, APPs can be better utilized to enhance quality and efficiency of care for patients with GU cancer?

A: Although I am a GU oncology NP, there are numerous adverse events (AEs) from the management of these malignancies that require input from other disciplines of urology, including voiding dysfunction, sexual medicine, and endourology, requiring me to have knowledge in each of these areas. Having training in all of urology during my fellowship has given me the tools and confidence to manage these issues on my own and the understanding of when to refer for a higher level of care. For example, the most common AEs of radical prostatectomy are urinary incontinence and erectile dysfunction. The fellowship allowed me to learn from our experts in each of these areas to appropriately manage patients on my own and [to gain] an understanding of when to advance the level of care for possible surgical therapies. So I can confidently manage a postprostatectomy PSA [prostate-specific antigen] but also any other urologic concerns that arise post therapy. Another benefit that I and one of my supervising physicians, Dr Smith, identified is that I am able to commit more time to management of these significant life-altering issues and formulate surveillance plans for our patients, ultimately allowing him more time for new patients, operating, or seeing our more complex patients.

Regarding managing postsurgical complications in this population, having spent time in the operating room as well as with our inpatient service has given me invaluable tools to acutely take care of patients in the possible urgent/emergent concerns in the postoperative period. It gave me awareness to know what I can manage in the outpatient versus when to admit someone for inpatient care.

Q: Over the next 5 years, how do you think the role of the APP will evolve, given the advancement of diagnostic testing and plethora of new therapies (and indications) across the various tumor types?

A: It is certainly an exciting time, witnessing and being a part of the advancements in diagnostic tests as well as novel therapies in urologic oncology. APPs are and will continue to be critical in the implementation and education for patients during the advancement of new tests and therapies.

During the past few months, I have worked closely with our medical oncology team and the hereditary cancer clinic to bring germline testing into the urology clinic for [patients at high risk of prostate cancer who] qualify based on the latest NCCN [National Comprehensive Cancer Network] guidelines. As an APP, I have the time to both set up the logistics of having a new test to offer as well as the time to spend with patients educating them on germline testing in high-risk prostate cancer. There have certainly been logistic hurdles along the way with incorporating a new test into our flow of these, but I have been fortunate to work with a multidisciplinary team to make this process both easy to understand and streamlined for our patients. As we mature our process in offering genomic testing in the urology clinic, our hope is that this multidisciplinary approach can be adopted at other institutions nationwide. Across urologic oncology, there are new and developing testing and therapies, including prostate-specific membrane antigen scanning, blue light cystoscopy, and novel intravesical treatments. With these complex advances comes the increasing need for a team-based approach in the care of our patients. The APP plays a special role as a medical provider closely working with the physician in management, as the patient advocate, and as a liaison for the multidisciplinary approach that these advances will require us to take.

Of course, this will require APPs to stay prudent on learning these changes and updates. We have all our APPs join the American Urological Association, which has vast amounts of education, lectures, and of course guidelines. Likewise, we encourage having NCCN accounts as well as memberships in the Society of Urologic Nurses and Associates and other groups to keep ourselves educated on the quickly changing landscape of urologic oncology.

Q: You are employed in a very highly specialized academic environment. What do you think would be the major critical pieces that independent urology groups should be considering in order to incorporate APPs into their advanced cancer care model?

A: APP utilization in urology is a topic that [many of my colleagues and I] are always working to improve and maximize. Before incorporating APPs into advanced cancer care, it is critical to start early with adequate education and training. As APPs, we are trained in primary care, where we learn how to medically manage patients. But making the transition to specialize and focus on a particular discipline can be a difficult task. That is where urology groups must take responsibility to provide adequate time and resources for newly hired APPs (those who did not complete a fellowship) to learn how to confidently manage the breadth of urology patients, and in this case urologic oncology patients. My APP colleagues and I have created a formal onboarding plan for newly hired APPs that requires more work on the front end but pays off when we have a new APP who can function independently.

Having worked in an independent urology group prior to becoming an NP, I have a good sense of the similarities and differences of independent groups versus academic urology. Regarding utilization of APPs, I don’t think our roles differ drastically. In independent urology groups, APPs likely work more as general providers [because] the physicians tend to see all areas of urology. If independent urology groups want to specialize their APPs into oncology roles, there are certainly efficient ways to do so.

Once you have an appropriately trained APP, the options for incorporating them into your advanced cancer care model are endless. An easy way to incorporate APPs into your model is to have the APP see the returns and [patients undergoing routine cancer surveillance]. This could be seeing patients for routine PSA monitoring or surveillance imaging and labs for patients with a history of urothelial carcinoma or renal neoplasms. This allows our MDs more time to see the new patients, the more complex patients, and even more time in the operating room. We even take advantage of this model in our advanced prostate cancer clinic. Patients [doing well on therapy whose PSA is stable], I can see … independently, draw labs, give any injections, address AEs/concerns, and send on their way, ultimately leaving Dr Moses more time with our new and more complex patients who often require extensive counseling and evaluation.

At Vanderbilt, our BCG/intravesical therapy clinic is managed by an APP. This includes not only giving patients their treatments but also managing AEs, questions, and concerns. This is an excellent way to utilize APPs, because intravesical therapies often come with a host of AEs that must be medically managed. Having an APP run an intravesical therapy clinic gives patients another provider who understands their pathology, diagnosis, and scheduled treatment plan.