Transformation of G1-G2 neuroendocrine tumors to neuroendocrine carcinomas following peptide receptor radionuclide therapy.

We observed that some patients with well-differentiated neuroendocrine tumors (NET) who received peptide receptor radionuclide therapy (PRRT) with Lutetium-177 (177Lu) DOTATATE developed rapid disease progression with biopsy-proven histologic transformation to neuroendocrine carcinoma (NEC), an outcome that has not been previously described. Therefore, we conducted a retrospective review of all patients with well-differentiated G1-G2 NET who received at least one cycle of PRRT with (177Lu) DOTATATE at our center from January 2019 to December 2020. Among 152 patients, we identified 7 patients whose NET transformed to NEC. Median time from start of PRRT to transformation was 8.2 months (range: 2.6-14.4 months). All patients whose tumors underwent transformation had pancreatic tail as the primary site and had prior chemotherapy with temozolomide. No differences in the incidence of transformation were observed according to gender, race, original tumor grade, or number of prior therapies. Six patients received treatment with platinum and etoposide after transformation with two patients having partial response as best response. All patients with transformation died from progressive disease with median overall survival (OS) after transformation of 3.3 months (95% CI 2.1-4.4). Molecular testing of transformed NEC identified mutation(s) in TP53 and/or ATM in all cases. Transformation of NET to NEC following PRRT is associated with aggressive course and dismal prognosis. Patients with pancreatic tail as the primary site who had prior therapy with temozolomide may be at a higher risk. Further investigation is necessary to determine the best treatment sequence in this patient population.

Cancer education in physician assistant programs.

PURPOSE: The purpose of this study was to describe the current state of oncology education provided by physician assistant (PA) programs. METHODS: This is a descriptive, cross-sectional study of PA programs using a web-based survey. RESULTS: The response rate was 22%. All programs reported dedicated curricular hours to address cancer: genetics, prevention/screening, diagnosis, and general treatment and counseling regarding delivering "bad news." The majority of programs provided 2 hours or less of content related to the evaluation and management of acute cancer treatment effects, oncologic emergencies, and symptoms of cancers/palliative care. Most common content areas without any dedicated time were management of patients with long-term sequelae of prior treatment or undergoing cancer surveillance and identification/management of cancer survivors. The most commonly used instructional format is lecture, interaction with preceptors, and direct patient care. Other forms of learning such as case-based learning and team-based learning are less commonly used. Most programs report the most common cancer patient encounters occur during internal medicine/primary care rotations. Although typically available, few students participate in oncology elective rotations. Data regarding faculty perception of cancer education, teaching resources, and barriers to teaching were also collected. CONCLUSION: Cancer prevention and initial diagnosis are the primary foci of instruction by PA schools. Instruction is typically by classroom lecture and clinical encounters during primary care rotations. Given the challenges faced by PA programs to provide a generalist's education for students, novel means of enhancing cancer education during PA school and continuing medical education following primary PA education will be essential to expand PAs' competencies in cancer care.

Understanding the role of physician assistants in oncology.

PURPOSE: To understand the deployment of physician assistants (PAs) in oncology. A recent analysis of the oncology workforce in the United States commissioned by ASCO predicted a significant shortage of providers by 2020. METHODS: A descriptive study was undertaken using a Web-based questionnaire survey. Invited participants, including all PAs listed in the national PA database (n = 855) and all PAs at The University of Texas M. D. Anderson Cancer Center (Houston, TX; n = 159), were mailed letters directing them to the Web-based survey. RESULTS: The study produced a 30% response rate. A total of 186 PAs worked in medical oncology (the population of interest). Of the respondents, 80% were women, mean age was 36 years, average time employed as a PA was 9.5 years (6.5 years in oncology), 55% had obtained a master's degree, four had completed a postgraduate oncology program, 91% reported that direct mentorship by a supervising physician was very important in obtaining oncology-based knowledge, and 61% reported that becoming fully competent in the practice of oncology required 1 to 2 years. The majority of PAs (78.5%) worked 33 to 50 hours per week, and 56% of those reported working 41 to 50 hours per week. Three fourths (77%) wrote chemotherapy orders, most requiring physician co-signature, and 69% prescribed schedule III to V controlled substances. Additional data were gathered regarding clinical duties, research, and teaching. CONCLUSION: Oncology PAs are used in multiple medical settings, and many assume high-level responsibilities. Future research addressing function and factors that limit use of PAs may allow for improved organizational efficiency and enhancement in the delivery of health care.

Physician Assistant Perspective on the ASCO Workforce Study Regarding the Use of Physician Assistants and Nurse Practitioners.

PURPOSE: A workforce study by the Association of American Medical Colleges (AAMC) predicted a shortage of 2,350 to 3,800 oncologists, or 9.5 to 15 million visits, by 2020. Proposed solutions included use of physician assistants (PAs) and nurse practitioners (NPs). Although 56% of the oncologists reported working with PAs/NPs, the AAMC did not survey PAs or NPs. This article uses additional data to examine the role of PAs/NPs in the oncology workforce. MATERIALS AND METHODS: American Academy of Physician Assistant (AAPA) census data and a study of PAs in oncology were used to examine these workforce issues. RESULTS: The AAMC reported oncologists working with PAs/NPs had increased productivity compared with physicians who did not, primarily when the PAs/NPs performed advanced roles or worked in private practice. Visits handled by PAs/NPs themselves were not reported. According to the AAPA, PAs in the outpatient setting saw an average of 62.4 patients per week (inpatient PAs saw 62.2 patients per week), supporting the AAMC report that 70% to 92% of oncologists experienced increased efficiency with PAs/NPs. Whereas the AAMC reported that 46.4% of oncologists used PAs/NPs in advanced roles, Ross et al reported that more than 70% of PAs wrote chemotherapy orders (most requiring physician co-signature); more than 80% wrote prescriptions, including for controlled substances; and more than half performed invasive procedures. The AAMC reported that 13% of PAs/NPs performed research activities, and the AAPA reported that 60.5% of medical oncology PAs participated in clinical trials. CONCLUSION: The AAMC workforce study inadequately examined the role of PAs/NPs in oncology. Given the available data in PA literature, the contribution of PAs/NPs to the workforce was substantially underestimated. In examining workforce issues, understanding opportunities for increasing collaborative practice requires the input of PAs/NPs.

Communicating with cancer patients: what areas do physician assistants find most challenging?

Physician assistants (PAs) and other midlevel practitioners have been taking on increasing clinical roles in oncology settings. Little is known about the communication needs and skills of oncology PAs. PAs working in oncology (n = 301) completed an online survey that included questions about their perceived skill and difficulty on several key communication tasks. Overall, PAs rated these communication tasks as "somewhat" to "moderately" difficult and their skill level in these areas as "average" to "good." Areas of most perceived difficulty were intervening with angry patients or those in denial and breaking bad news. Highest perceived skills were in communicating with patients from cultures and religions different than your own and telling patient he/she has cancer or disease has progressed, and the lowest perceived skills were in discussing do not resuscitate orders. There are areas in which enhancement of communication skills may be needed, and educational opportunities should be developed for PAs working in oncology.