Defining the Role of Oncology Advanced Practitioners in Equitable Cancer Care Delivery

J Clin Pathways. 2021;7(7):14-16.

The Association of Community Cancer Centers (ACCC) and Harborside co-hosted virtual Summits on March 30, April 1, and April 6, 2021 that connected oncology advanced practitioners (APs)—defined as nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), and oncology pharmacists—with oncology and non-oncology physicians and patient advocates. Participants engaged in focused conversations on equitable cancer care across three domains: care coordination and communication, clinical trials, and acknowledging and mitigating implicit bias.

After the Summits, action steps identified in each of the discussion domains were collated. Participants ranked these recommendations via an online polling platform according to two criteria: feasibility and impact. This consensus-driven process identified the action steps that received the highest scores (ie, the most votes for both feasibility and impact). This process helped define 10 feasible and impactful opportunities for oncology APs to play a greater role in equitable cancer care delivery:

1. Encourage and engage in active shared decision-making. Participants identified a need to create resources that help APs foster open dialogue with patients and engage in dynamic shared decision-making that elicits a patient’s care preferences. 
2. Identify existing data collection metrics and equity screening tools. A unifying theme across the Summit sessions was the need to curate and build on existing resources. Participants supported establishing a working group of APs to conduct a literature review (including grey literature) and research to aggregate existing data collection measures and screening tools. The importance of identifying tools that integrate into electronic health records (EHRs) was emphasized. Participants agreed that such resources were vital to accurately measure health disparities, demonstrate the value of care coordination, and help to develop an understanding of where and how breakdown in care coordination/communication occurs, relative to disparities for specific patient populations. 
3. Deliver a consistent message about clinical trials. Participants agreed that APs can help level-set clinical trials for patients and all members of interdisciplinary teams by delivering a consistent message that clarifies how clinical trials represent a standard of care, and that every patient with cancer should be considered for clinical trial participation. They recommended advocating for cancer programs/practices to include “discussion of clinical trials” in AP job descriptions.
4. Step into research. Many oncology APs have an interest in greater participation in research. Summit participants agreed that APs in oncology are often ideally situated for conducting health disparities research. To extend the AP’s role in research, participants recommended development of quality improvement CE/CME education programs so APs can gain the added skills that are needed to plan and conduct research.
5. Advocate for inclusive cancer clinical research. Research-focused APs working at the top of their licensure have proven capacity to engage in all aspects of clinical research, including serving as principal investigators (PIs) and co-PIs. Summit participants strongly agreed that advocacy to enable APs to sign off on clinical trial orders is an important step in support of their evolving role on clinical research teams. Often the healthcare professionals most engaged with clinical trial participants, On behalf of their patients, APs can amplify patient-voiced barriers to trial enrollment, challenges faced by patients who are participating in clinical studies, and at the trial’s completion, the importance of sharing aggregate trial results with study participants. 
6. Support and engage in research publication. Summit participants agreed that the AP’s role in publication, curated resources, tools, and education must be expanded. Areas of opportunity cited by participants include unpublished clinical trial data that APs may use to develop and publish original research papers as lead author and co-authors, particularly in the area of novel agent adverse event prevention, mitigation, and management. 
7. Ask for training resources for APs related to diversity, equity, and inclusion in clinical trials. Elevating equitable care delivery requires ongoing learning and commitment, participants acknowledged. Advanced practitioners need access to training resources, such as short videos, podcasts, or webcasts that explore issues related to diversity, equity, and inclusion in cancer clinical trials. These resources should include APs interacting with patients to describe trial enrollment, what participation in a clinical trial entails, and the voices of patients who have participated in clinical trials. 
8. Create a checklist to support a top-of-mind focus on equity. An equity-focused checklist can serve as a low-cost, easily integrated tool—ideally into the EHR—that APs could use to support awareness of implicit bias. Summit participants recognized that implicit (or unconscious) bias exists in all human beings and is a consequence of how the human brain is hardwired. At the same time, awareness of the subtle ways that   implicit bias may affect equitable cancer care delivery through a process of regular self-assessment, intervention, and re-assessment is essential to effect change at the individual level. 
9. Call for equity in medical professional curricula. During Summit discussions, some participants shared their lived experience with biases embedded in professional education and training. Participants agreed that APs have a role in advocating for medical professional graduate programs to examine their curricula and to take action to address explicitly and implicitly biased training, including the requirement that faculty be trained in implicit bias awareness. An additional call to action is for APs to encourage their professional organizations/societies to join in a collective statement of support for this action to graduate curriculum programs and accrediting/credentialing bodies.
10. Request that your professional societies reserve space at events and in publications for discussion of implicit bias education and equity in cancer care delivery. Advanced practitioners, together with professional organizations such as American Academy of PAs (AAPA), ACCC, Advanced Practitioner Society for Hematology and Oncology (APSHO), Harborside, and others can commit to publishing on these issues to help disseminate best practices in moving toward more equitable cancer care delivery. 

Read the full executive summary, including current state, future state, and action steps from each of the three Summit discussions listen to related podcasts, and access additional AP resources online at: accc-cancer.org/OAP.