NEW YORK – Lindsay Carlsson, an oncology nurse at the Princess Margaret Cancer Center, is spearheading a virtual care consultation program for metastatic breast cancer patients across the Canadian province of Ontario, aiming to improve their access to comprehensive genomic profiling and clinical trials.
The nurse navigator-led virtual care pathway will officially launch this fall with grant funding from Pfizer Canada and the Canadian nonprofit Rethink Breast Cancer. Though the pilot program has received funding for one year for patients with metastatic breast cancer receiving standard of care in Ontario-based community cancer centers, Carlsson and her team hope that this type of support will eventually become part of the care patients with other kinds of cancer receive, as well.
According to Carlsson, the program facilitates communication with advanced cancer patients early in their care, rather than once they have experienced recurrence or relapse on available therapies. The program also spurs collaboration between nurse navigators at comprehensive cancer centers like Princess Margaret and community practices where patients frequently receive their diagnoses and first line of treatment.
"Currently, [at Princess Margaret] we see patients at the time when their current anti-cancer therapy is no longer effective and they're referred to our team," Carlsson said, explaining that under this current model, these patients may not know about biomarker testing options or clinical trials until their cancer has progressed. "It's not the most effective way to do things, and this [program] kind of flips that on its head."
Instead, Carlsson and her team at Princess Margaret are inviting community oncologists from across Ontario to refer their advanced breast cancer patients to the virtual pathway program early in their treatment trajectory, around when they begin their standard-of-care treatment.
Patients referred to the program will have a virtual consultation with the nurse navigator, in this case, Carlsson. In these consultations, Carlsson gets to know the patient, their cancer journey, their overall health, and the specifics of their diagnosis and enters these details into a medical record for the patient at the academic cancer center. The sessions also offer Carlsson the chance to start educating patients about clinical trial opportunities and the value of genomic profiling tests.
The patient — who is still under the care of their primary oncologist at their community center — also has a virtual meeting with an oncologist at Princess Margaret to address treatment-related questions and establish a connection. Following these initial conversations, the nurse navigator sets up a tailored plan to check in with periodic calls as the patient undergoes their treatment in the community setting.
"And then, at the point in time — if and when that time comes — when the patient's current treatment is no longer effective, we can then expedite them to get into seeing our team [at Princess Margaret]," Carlsson said. "And because I will have been following them virtually in the community, the idea is that we will be able to anticipate potential trial opportunities for them and communicate those options to them and their oncologists. It's a much more anticipatory type of approach compared to what happens currently."
Earlier molecular profiling access
From the start, patients in the program are also given the opportunity to have comprehensive biomarker testing, which may identify opportunities for biomarker-selected clinical trials or targeted treatments should the standard-of-care treatment stop working.
To get tested for free through the program, patients will need to come into the Princess Margaret Cancer Center and provide a sample and their consent. They'll provide blood samples for tumor-normal profiling and next-generation sequencing, though based on individual patient cases, Carlsson said there may be opportunities for patients to enroll in protocols for newer genomic profiling approaches such as liquid biopsy. The Princess Margaret team will then share the molecular testing results with the patient and their primary oncologist via the communication channels established in the virtual care pathway.
"Within the province of Ontario, molecular profiling is really limited to a small number of disease-specific indications," she said. "And unfortunately, access to this more comprehensive profiling, which is what we're offering through this project, is usually limited to enrollment in a research project in urban academic centers or commercial testing, which can involve significant out-of-pocket expenses."
According to MJ DeCoteau, the founder and director of Rethink Breast Cancer, one of the key reasons that Rethink and Pfizer Canada selected this project as one of three recipients of a quality improvement grant was that the model has the potential to address genomic profiling access disparities.
"This funded project aims to increase access to patients receiving treatment in community-based hospitals, so that large teaching institutions are not the only access point to genomic profiling," DeCoteau said. "The specific project is very aligned to Rethink's work to educate, empower and advocate for … historically underserved groups [including] people diagnosed at a younger age, those with metastatic breast cancer, and people systemically marginalized due to race, income, or other factors."
Pfizer Canada and Rethink would not share the exact amount of funding awarded through the grant, though funding for the three programs together, including this one, totaled C$280,000 (US$217,605).
A bigger role for nurse navigators
As part of the grant agreement with Pfizer Canada and Rethink Breast Cancer, Carlsson's team at Princess Margaret will collect metrics throughout the yearlong initiative to assess whether, and how well, it moves the needle on access to clinical trials and genomic profiling. Carlsson said the team aims to publish its findings, including metrics like trial recruitment numbers and patient-reported outcomes, toward the end of 2023 or in early 2024.
According to a spokesperson for Pfizer Canada, the drugmaker and Rethink Breast Cancer will jointly review project reports to determine if and how this initiative can be adopted more broadly across Canada.
Carlsson is optimistic that the model under pilot in breast cancer has the potential to transform access to precision oncology more broadly, but says it will depend on the availability of designated nurse navigators. Virtual care pathways take time that oncologists, administrative staff, and clinic nurses may not have. "This will take creating more opportunities for nurse navigators," she said, adding that the role is gaining recognition at cancer centers in Canada and the US and will become a more integral part of care teams in step with greater adoption of precision oncology.
Indeed, in a Precision Oncology News-led survey last year of oncologists mostly from academic cancer centers and large health systems, nearly a quarter of respondents said that nurse navigators were important intermediaries for facilitating biomarker testing and patient follow-ups.
Scaling the program will also take additional investment in communication frameworks between academic cancer centers like Princess Margaret and community oncology settings. Standardizing the frequency and quality of this communication could require additional manpower and infrastructure, Carlsson said. "Community oncologists are incredibly busy managing large patient loads and complex care," she said. "That's another part of the thinking behind this project: How do we take a load off them?"
That said, the program is not designed to encroach on patients' relationships with their community oncologists in terms of treatment decisions. "Obviously, the patients are under their care, so we work very closely with them and leave all treatment decisions with them," Carlsson noted.
But given the pace of precision medicine advances, most community oncologists welcome help when it comes to biomarker-informed care. This has been Carlsson's experience so far.
"The reception has been incredibly positive," she said, acknowledging the program is still in its infancy so the feedback is purely anecdotal. "Based on what we've been told … the oncologists don't feel like their patients are potentially missing opportunities."