In an interview with Oncology Nursing News, Caitlin Benda, MBA, MS, RD, CSO, LDN, a clinical oncology nutritionist supervisor at American Oncology Network, comments on different ways oncology nurses can assist patients in reaching their overall caloric intake. Read the article.
I had the recent honor and privilege to once again co-Chair the Community Oncology Alliance (COA) annual Community Oncology Conference, which featured two days packed with medical updates, legislative updates, best practice patterns, patient advocacy efforts, and networking with colleagues and thought leaders.
As our largest conference to date with over 1,500 attendees, it was a hugely impactful meeting, highlighting and addressing the issues currently facing community oncology practices. This blog shares what I considered to be the main take-aways from the conference, including the challenges and opportunities that lie ahead.
Old story, new verse. We engaged in extensive discussions regarding the ongoing abuses of the 340B Drug Pricing Program.
Although initially developed to improve patient access to care, the 340B program has been hijacked by numerous health systems to fund expansion of hospital-owned physicians and infusion centers. It has, paradoxically, increased patients’ costs due to higher site-of-service fees and subsequent drug price increases issued by Pharma to offset the 340B subsidies to these institutions, thereby actually limiting patient access to care.
Additionally, these 340B-based health systems leverage excess drug margins, pressuring community oncology practices to capitulate and join their fold, again resulting in limited sites of service and higher costs for more patients. This erodes the community oncology platform that repeated studies have shown to be a more efficient and cost-effective means of providing oncology care.
Though Congress has issued some cuts to 340B reimbursement, we as Community Oncology must remain diligent and united in continuing to shed light on program abuses as a major cost-driver in oncology care.
The evolution of pharmacy benefit managers’ (PBMs) influence in oncology and specialty care is almost beyond comprehension. They have always been among the most egregious offenders in terms of patient access issues through their use of step-edits, prior authorizations, limited formularies, out-of-network exclusions, and veiled rebate systems which drive price increases.
DIR fees PBMs charge to pharmacies and dispensing practices have increased over 1000% in the past few years with little to no transparency regarding the justification for, or utilization of, these funds.
The vertical integration of PBMs within payers shows how valuable they are as a profit center. The consolidation in this space has left us with only three PBMs managing approximately 80% of prescribed medications in this country – limiting competition, which results in further price increases and even more limited access.
A concerning trend is the exclusion of high-cost drugs from formularies, with PBMs expressly directing the patient and provider to apply for compassionate/free drugs from Pharma. This has become almost epidemic.
An unconscionable development is the alliance of PBMs and 340B institutions, which are joining forces to gain access to 340B discount pricing on PBM managed drugs.
Multiple Pharma companies have boycotted this effort, which will undoubtedly drive prices higher. Stay tuned as this will be decided in the courts later this year
OCM and Value-based Models
Another significant issue discussed at COA was the sunsetting of the Centers for Medicare and Medicaid Services’ (CMS) Oncology Care Model (OCM). Though the published data for this model suggested overall minimal financial benefit to CMS, the value to our patients is unquestionable.
Oncology practices throughout the country have dedicated millions of dollars in resources to reposition their practices as value-based sites. Through additional patient support networks and improved 24-7 access to their oncology caregivers, this effort was clearly successful in minimizing high cost, low benefit emergency department visits, hospitalizations, and improving timely access to palliative care services.
The funding for these patient touchpoints is in jeopardy unless a new value-based model is enacted by CMS. Appropriating funding for incentives that improve access to and reduce the cost of care should continue to be a high legislative priority. In the meantime, a pivot to professional case management, transitional care management, and chronic care management programs supported by CMS may offset some of these expenses.
No longer a “pie-in-the-sky” quip, precision medicine is rapidly becoming a reality in oncology.
The most cost-effective treatment for our patients will always be the “right” treatment, which is best defined with NGS biomarker panels, whole exome sequencing, RNA/transcriptome sequencing, germline testing, and pharmacogenomics. The complexity involved in the analysis of this tidal wave of data, coupled with the exponential development of targeted agents, creates a challenge for the community oncologist. This data needs to be codified and quantified in a usable format that can be integrated within our EHR’s to power therapeutic decision-making, treatment selection, and monitoring for our individual patients in multiple lines of therapy.
We will likely need to employ the help of artificial intelligence (AI) based solutions to achieve this goal. I strongly believe that Community Oncology will lead the way in this endeavor.
The continued growth and success of Community Oncology will be driven by our response to these challenges. How we react to adversity rather than the adversity itself will define our path forward.
Resilience has long been the cornerstone of community oncologists. Fueled by innovation, ingenuity, and a commitment to patient-centered care, we can and will create a brighter tomorrow for our patients and their families.
My experience delivering diagnostic pathology services within the laboratory and in the patient exam room have made clear the importance of pathologists serving alongside oncology care teams. The success of these collaborations is driving change in the pathologist’s role in providing precision care.
A complete and accurate pathology report is crucial to diagnosing patients and deciding on the best treatment plan. Pathologists are highly skilled and experienced members of the care team, specializing in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. We use state-of-the-art equipment and the most advanced techniques to analyze tissue samples.
As part of my journey, I’ve participated in diagnosing multiple challenging and interesting cases and have collaborated with our network’s oncologists by providing crucial laboratory results that determine an array of cancer therapeutic decisions.
Pathology Reports Are Not Always Clear
Pathologists’ important work on the oncology care team can often be obscured by reports that are not meant for patient consumption. In particular, pathology and ancillary test reports are not written at a level most patients can understand. It can be discouraging for the diligent and engaged patient who proactively seeks out detailed information about their lab results and what these might mean for the prognosis.
According to the Association of Community Cancer Centers, these reports may also be organized in ways that are confusing to both clinicians and patients. While some patients may meet or speak with pathologists, most pathologists don’t have the time or training to explain their findings directly to patients – a significant hurdle in today’s healthcare environment.
However, as calls for advancements in precision medicine grow louder, so too are calls for ensuring information from pathology is presented in a consumable, patient-friendly manner. The National Academy of Medicine recommends “good communication about key findings” of the reports for patient use. “Pathology report and ancillary test results are integral to patients fully understanding their disease, treatment options, and participation in shared decision-making. Put another way, when patients can access the key information from their pathology and ancillary test reports, in patient-accessible formats, patients can be empowered to understand their disease and treatment options better and engage in the shared decision-making process with their care team.”
Delivering Consumable Pathology Reports for Patients
To deliver the highest level of consumable information about the precise nature of a patient’s condition, some steps to take may include giving the patient a list of reliable sources for additional information about their cancer, connecting patients to cancer-specific advocacy and support groups, and providing patients with patient-centered education and resources for additional information, such as clinical trials.
Clinicians have access to experts and resources designed to help them better understand the information contained in pathology and ancillary test reports. Paired with the reports prepared by pathologists, which they can use to guide shared decision-making conversations about treatment plans, patients can use this information to refresh their memory about the details of their condition before speaking with clinicians.
The role of pathologists is increasingly vital in the practice of precision cancer medicine because of the continuous advances in genomic and molecular testing and the transformation of the traditional exclusively high-level practice of pathology into a more molecular-based medical specialty, as well as the desire for more consumable information related to precision medicine.
Continuously adapting with the newest medical discoveries to provide the most accurate and informative cancer diagnoses for our patients remains paramount, but it’s only one of our charges. By integrating pathologists into patient care teams, we can provide more comprehensive strategies for managing information sharing and meeting the requirements of precision medicine for all patients in our network.
Engaging patients in portions of their care, even those areas that can be difficult to translate and communicate, is a step toward holistic, whole-person care.
Before 2016, there was little going on regarding value-based care in oncology. That changed with the introduction of the oncology care model (OCM), the intention of which was to better align financial incentives to drive improvements to care coordination and appropriateness, as well as expand access to care for patients undergoing chemotherapy.
After six years, the pilot program is at its end. OCM encouraged participating practices to improve care and lower costs through an episode-based payment model that financially incentivized high-quality coordinated care. Fine in theory, but not so easy in practice.
Despite its demise, OCM significantly impacted the practice of oncology, and great strides in patient care were nonetheless realized.
The Benefits of OCM
Participating in OCM helped transform practice operations within the AON network to focus on patient experience more than ever – rather than simply delivering care. Additionally, the investments we made in services and a quality-based care infrastructure to support associated OCM program requirements will continue to deliver value to our patients and practices.
OCM required the delivery of care plans directly to patients, which our physicians did excellently. Before OCM, most in oncology care were not driven to provide care plans and documentation directly to the patient. Oncology was about care delivery less than it was about coordinating or including the patient in the care. OCM required that patients received information about their care plans in a shareable format that patients could use as they wanted.
With the cessation of OCM, the most significant disadvantage for patients is that they may face a more difficult task of acquiring patient information in which they can act upon. For example, when a patient is newly diagnosed with cancer, they typically retain very little of the information discussed around prognosis, treatment options and treatment plans. Compliance with OCM data guidelines helped patients retain this knowledge.
In fact, the required care plans were one of the best things to come from OCM because they easily translated to meaningful, patient-friendly paper documents outlining all the information a patient needs to understand their diagnosis and treatment. Though this information has always been in the patient’s chart, through OCM they also had something tangible to share with their families and loved ones. This shareable information led to patients being more engaged in their care and asking questions related specifically to their treatment plans rather than engaging in a more nebulous manner. That’s been a positive impact, useful for patient navigation.
Participating in a large value-based care arrangement like the OCM has been invaluable for AON, our practices, physicians, and patients. While participation was voluntary, most who took part did so by embracing it fully. That is why I don’t believe value-based care practices or the principles of OCM are going away – nor do I believe any other healthcare providers want it to go away.
Unfortunately, the most significant problem before OCM was that payers were not fully prepared for how to address value-based care in oncology. Treating cancer is very expensive and oncology drug prices are unpredictable, which is likely a significant deterrent for some commercial payers when it comes to developing any type of shared savings program for community oncology practices. The overwhelming challenge faced by payers is alignment of interaction and reimbursement. It is a complicated, detail-driven challenge where various payment models and contracts created roadblocks to streamlining payment mechanisms.
When OCM officially concludes on June 30, 2022, there is no other quality program coming online in its place – making it a challenge to maintain an oncology value-based care program. Outside of organizations like AON, there are likely some very real challenges ahead for practices as they attempt to do so. Most invested in services and infrastructure to support participation in OCM, and will likely lose at least some momentum without another value-based model to follow, especially regarding data collection and dissemination.
However, for practices within the AON network, basing care on quality over all else remains a priority. We continue working with our practice partners to ensure training and education related to value-based care. We make clear the benefits and put in the work to prove the value of value-based care for patients and practices. We’ll continue to follow the structure of OCM – every practice transformation effort that we put into place will continue – because it is flourishing. We will not revert to pre-OCM care.
Our patients are the ones who win in the end, and that’s why we’re here – to provide the very best care for our patients, with or without a formal OCM program.
As the sun sets on another year dominated by an evolving and unprecedented global pandemic, we find ourselves on the threshold of what promises to be another year of familiar challenges. To address them, American Oncology Network (AON) will leverage the many lessons learned from our experiences clearing the hurdles presented by 2021 while maintaining focus on our primary mission of ensuring our partner practices can continue providing patients with top-quality care.
In fact, despite the ongoing challenges of COVID-19 and the changes it has necessitated to the practice of oncology and the healthcare industry, AON realized several milestones over the past year. We’ve grown to more than 100 physicians in 16 states and expanded both the clinical trials underway within AON sites and the volume of non-oncology infusion services offered by many of our practice partners.
These are just a few of the ways AON is continuing to help keep community oncology viable so that patients have access to affordable yet high-quality care close to home – a commitment that takes on greater significance as we gear up for another battle against a round of cuts to Medicare physician reimbursements that will take place in the spring without additional action by Congress.
Cuts Delayed, But Not Gone
While recent action by Congress has given providers a reprieve from what would have been financially devastating reimbursement cuts totaling 9.75%, it could be short-lived. That’s because the legislation passed in mid-December only extends until April a moratorium on the 2% Medicare sequestration relief originally mandated by the Budget Control Act of 2011 and in effect since 2013 – cuts that had already been delayed three times due to the pandemic. A 1% sequestration cut (which will impact both Traditional and Managed Medicare) will be in effect from April thru June 2022 with 2% going into effect the remainder of the calendar year.
The package, which is now with President Biden, also prevents a 4% cut due to statutory budget rules known as “PAYGO,” which require Congress to pass legislation in a deficit-neutral manner or automatic sequestration is triggered at the end of the year. It also offsets a rate cut finalized in the Medicare Physician Fee Schedule final rule from November that was originally slated to happen due to the expiration of a temporary across-the-board increase previously authorized to partially offset cuts triggered by the 2021 MPFS Final Rule.
It’s important to note that the fight is not limited to the pay cuts. Should the temporary rate increase to lessen the blow of the 2021 MPFS Final Rule be allowed to expire, the Centers for Medicare and Medicaid Services (CMS) will factor that into the conversion factor as outlined in the 2022 MPFS proposed rule lowering reimbursement by 3.75%. Further, the 2022 Medicare Hospital Outpatient Payment System and Ambulatory Surgical Center Payments Systems (HOPPS) proposed rule included the mandatory Radiation Oncology Model (ROM) would lower physician reimbursement rates and create uncertainties that will negatively impact providers and patients.
A Voice for Community Oncology
While the current delay is certainly reason to celebrate, the fight is far from over. AON will continue to do everything in our power to ensure the voice of community oncology is heard in the push for Congress to take action to prevent what will be a devastating 9.75% cut in Medicare physician pay from taking effect in April.
We encourage practice leaders, physicians, and the entire AON provider network to join us by contacting their senators and requesting that the necessary action be taken to protect reimbursement rates. Addresses and phone numbers can be found here.
Winning this fight will protect community practices from a potentially devastating financial blow that could have long-term implications for the scope of care they’re able to provide to their patients.
November 11 is Veterans Day, celebrating America’s military veterans, their service and the contributions they’ve made to the nation’s well-being and ensuring its freedom. According to the United States Census Bureau, there are currently about 18 million veterans in the US, with service experience ranging from World War II to Afghanistan.
In honor of the holiday and to help celebrate the nation’s veterans, we spoke with Jonathan Sharrett, DO, a Board-certified radiation oncologist with Summit Cancer Centers, an American Oncology Network partner, and Spokane CyberKnife. A military veteran, Dr. Sharrett enlisted into the US Armed Forces after high school and served from 2002 through 2008. He deployed twice to the Middle East in support of Operations Enduring Freedom and Iraqi Freedom, was a member of the Honor Guard and a military fitness instructor.
During his service, Dr. Sharrett’s grandmother lost a courageous battle with Stage IV breast cancer and his mother beat Stage IV Burkitt-Like Lymphoma. These events shaped the trajectory of his life, as his purpose and mission quickly evolved into a career in medicine.
After leaving the military, Dr. Sharrett earned his medical degree from Edward Via College of Osteopathic Medicine and completed his residency at Cleveland Clinic before joining Summit Cancer Centers and Spokane CyberKnife. In this interview, he speaks about his path to radiation oncology, his military career, the importance of service to him and his family, and how the military has helped his medical career.
Was medicine a consideration when you joined the military?
Not one bit. I grew up in a trailer park in a small rural town in east Tennessee. No one in my immediate family worked in medicine or had more than a high school education. My family was very patriotic, though. My dad was in the Army, my brothers were in the Navy, and I had uncles who were infantrymen in the Marine Corps who served in World War II in the Pacific Theater (Iwo Jima and Saipan). I was patriotic too, so when 9/11 happened, I was all about the military. That was it; it changed everything for me.
Regarding your decision to go into medicine, specifically oncology, what factors got you here?
My grandma was diagnosed with Stage IV breast cancer when I was still in high school. Then, while I was deployed in the Middle East, I found out my mom had Stage IV aggressive lymphoma. I already had a powerful interest in fitness and nutrition and their diagnoses made me want to learn even more about the body, so I started down the healthcare path as I was on my way out of the military. I thought about being a dietitian at one point, and I was already a personal fitness instructor for military professionals and a personal trainer. But I soon realized I knew more than I thought and considered being a nutritional biochemist. Then, at some point, I said ‘you know what? I’m just going to be an oncologist.’
My dream was to be a medical oncologist. But in my third year of medical school, I met a radiation oncologist who said, ‘why don’t you come hang out with me.’ The next thing you know, I was visiting MD Anderson and Emory University in Atlanta for clinical rotations, and I found myself on the path to radiation oncology.
But first and foremost, it was driven by my family.
Did the discipline you acquired in the military help you through medical school and now in practice?
Absolutely. The military – the discipline, attention to detail, focus, and challenges you face – created an environment where nothing could faze me. The setting helped me interact well with people from different backgrounds, be rational, and maintain level-headedness. I started out training in the bomb squad (Explosive Ordnance Disposal), which meant I had to dedicate time to studying and preparing and, for obvious reasons, I had to be exceedingly disciplined. While I ultimately decided that was not the job for me, the intense training definitely set the standard for how I would approach future endeavors. The military also gave me a sense of confidence in myself that I didn’t know I had. All of that had a significant impact on my ability to stay hyper-focused through medical school and the other tough challenges I encountered along the way.
What do you love most about radiation oncology?
I love the opportunity to help people by drawing on multiple facets of my life – not just as an oncologist. For example, because of my personal experiences, I understand the patient journey. My mother had a lot of questions about her cancer that didn’t get answered, my grandmother too. Many people are confused about their care, so when I walk into the room to see a patient, I want to know how I can maximize that interaction and make a difference in their life, whether I end up treating them or not. Even if it’s not related to cancer, I enjoy going in every day and having that mindset of wanting to help make someone’s life better or help them through this process that they’re going through. This is my anchor – helping people. And that’s what I love about it.
What accomplishments are you most proud of?
Going through the whole process of getting out of the military, going back to school – especially coming from a small town – and going to a small medical school. That’s all extremely important to me. Also, going to Cleveland Clinic for training and completing the journey of becoming Board-certified were significant accomplishments and I’m proud of them. However, most importantly, I’m proud that my parents are proud of me, that they are still alive to see the success I’ve had, and I can remind them that I wouldn’t be where I am today without their love and support throughout my life. It makes me happy to know they can see the fruits of their labor.
What have been some of the main challenges in your journey from military to medicine?
The biggest challenge moving from the military to civilian life was the loss of the camaraderie and brotherhood that you have in the military. It’s not the same out in the real world. Veterans yearn for that kind of sense of belonging. Your military colleagues understand what you did, where you came from, and what you sacrificed for the country. They get the loss and understand the emptiness of not having that interaction. It’s challenging to recapture that out in the real world. It’s almost like what you might feel in highly functioning/competitive athletics or when playing on a team – the team bond – where everyone has a defined role and works hard for each other and not just their own interest to accomplish the goal at hand. That’s hard to replace. The structure the military provides in one’s life is also very important and just not the same out in the real world, although some medical settings do come close.
The closest thing I came to that so far was during my training in radiation oncology at Cleveland Clinic where just the teamwork and esprit de corps was close. It made me feel almost like the military again, because they were demanding and had high expectations like the military, but also very supportive and had your back and refused to let you fail. I think that’s one of the reasons why Cleveland Clinic is such a great place. Lack of camaraderie and structure is a challenge for many veterans as well.
What message would you share with a student whose finishing high school and thinking about the military or medicine?
I would tell them that the military is a fantastic experience. It gives you a sense of identity, purpose, teamwork, and pride in where you’re from. It gives you opportunities to leverage what they offer to then launch into whatever you want to do in your life. It provides individuals with a lot of good structure and discipline that can benefit their lives. I would highly recommend military service to almost anyone coming out of high school, especially those uncertain about what they want to do with the rest of their lives.
Are there any mentors that you’d like to note for having helped you through your career?
I had so many along the way! One who was most important was my calculus teacher in high school, Coach Thompson. He was a significant mentor when I was starting to excel in school. He saw that and mentored me and helped me through. We stayed in touch while I was in the military and when I would go back to Tennessee, we would go to Tennessee football games together. He gave me the sense that I was worth more than I thought. After the military, a great mentor of mine was the chairman of the Department of Radiation Oncology at Cleveland Clinic, Dr. John Suh. And, of course, my dad!
How would you like people to recognize Veterans Day?
Try to take a step back and see, from their perspective, the sacrifice veterans make for our country and what they’ve been through. A sad thing is the impact of veteran suicide and those who are on the streets and homeless. What happened? How did they get there? How can we help them, support them, and be there for them? They gave a lot for our country. They should be acknowledged and supported on more than just Veterans Day.
We should find ways to uplift them and help them feel part of society when they come out of the military. It’s a big thing, because many of these servicemembers are leaving Iraq, Afghanistan, and military service in general with understandable mental health concerns, and other physical ailments and health-related issues. How they integrate back into civilian society is so important, so being compassionate and empathetic and finding ways to help them along their journey as they transition back to everyday life is something we can all do, in some capacity, either directly or indirectly. Show them honor and respect – I’m grateful to those who already do.
Anytime I have a patient and I’m aware that they’re a veteran, I make sure that I acknowledge that. It goes a long way toward thanking them for their service to our country.
October 19 is 2021 National Pharmacy Technician Day – the ideal time to demonstrate the value these technicians bring to patients and patient care outcomes.
Pharmacy technicians play a significant role in pharmacy operations. Their contributions are numerous and allow pharmacists to stay focused on performing to their highest level possible. It’s no exaggeration to suggest that pharmacy technicians are in many ways the backbone of pharmacy operations.
The Pharmacy Tech’s Role
Pharmacy technicians can be found in many healthcare environments – retail and hospital pharmacies, practice-based pharmacies, even insurance companies and pharmacy benefits organizations – and their roles and responsibilities vary by setting.
For example, a pharmacy technician who works in the neighborhood retail pharmacy under a pharmacist’s direction will typically be dispensing medication, compounding topicals and ointments, and handling billing insurance for services. In hospital settings, technicians handle medication reconciliation, prepare and compound IV solutions, maintain and restock automated machines, dispense medicines, and conduct inventory control.
In specialty clinics like the community-based oncology practices that are part of American Oncology Network (AON), pharmacy technicians provide vital support to the clinical staff. The oncology setting is a complex ambulatory care environment where pharmacy technicians must possess the highest levels of professionalism, knowledge, and efficiency. In addition to standard pharmacy responsibilities, technicians also serve as liaison between nurses, physicians, financial counselors, and management to address drug order needs.
In addition to the tasks described above, pharmacy technicians are responsible for reviewing and performing pharmaceutical calculations for medication orders, drug admixture, inventory control, asset services, operations, education and training, informatics, quality improvement initiates, procurement, and thorough project management depending upon the setting.
AON pharmacy technicians have access to Board-certified clinical pharmacists and resources that are essential to the medication preparation process, as well as support from pharmacy administrators who help guide clinic pharmacy technicians on industry best practices.
Opportunities for professional development are numerous for AON’s pharmacy technicians. For example, AON will reimburse full- and regular part-time pharmacy technicians who successfully pass the national Pharmacy Technician Certification Board Exam for the cost of the exam and recertification renewal fees.
AON also encourages its certified pharmacy technicians to pursue additional credentials through the National Pharmacy Technician Board. As the profession grows, other credentialing programs are being created, including CSPT (Certified Compounding Sterile Preparation Technician) and CPhT-Adv (Advanced Certified Pharmacy Technician).
Additionally, there are certificate programs they can pursue, such as Hazardous Drug Management, Immunization Administration, Billing and Reimbursement, and Management of Controlled Substances.
At AON, we believe training is the key to success, and success is obtainable on all levels, and our programs are second-to-none.
Partners in Care
Above all else, pharmacy technicians are partners in patient care. They take pride in the role they play in achieving the best possible outcomes and approach each interaction as if it were with their own family member. AON, in turn, provides our pharmacy technicians with the support they need to practice at the highest level. This includes providing opportunities they may not have with other organizations.
Pharmacy technicians are valuable members of the care team and pharmacy operations as a whole. Which is why AON is proud to celebrate National Pharmacy Technician Day and recognize their unwavering commitment to excellence.
Cancer is hard – physically and emotionally. The diagnosis alone can trigger fear, uncertainty, and stress, all of which can be exacerbated throughout prognosis discussions, treatment decisions, procedures and just managing the normal activities of daily living with this dark shadow lurking in the background.
Anxiety is also part of the mix, even when a patient moves out of treatment and into survivorship. Undergoing scans to monitor for possible recurrence. A health change even years after getting the “all clear.” Annual physicals with their primary care physician. All these situations can trigger the same overwhelming emotions the patient felt throughout their initial battle with cancer.
For some, cancer feels like a life sentence that carries an enormous emotional penalty. Which is why supporting a patient’s mental health needs is an important component of a comprehensive care plan.
Mental Health Challenges
A cancer diagnosis and subsequent treatment can bring forward several mental health issues, the most common being anxiety, depression, and adjustment disorder. While patients who have struggled with these and other mental health disorders in the past are more susceptible, the cancer diagnosis and all that comes with it can trigger symptoms in any patient. It can also exacerbate disorders that had previously been controlled.
While most symptoms will fall on the mild end of the spectrum, they can evolve over time into something more severe and long-lasting. For example, though uncommon, some cancer patients find themselves with symptoms much like post-traumatic stress disorder (PTSD), usually resulting from a traumatic experience during treatment such as an adverse or unexpected surgical outcome.
Many patients also struggle with feelings of guilt related to their illness. Guilt could stem from thoughts about not being able to manage chores or tasks as well as before. They may also experience worry that they are a “burden” to someone else. Guilt is not always rational, but if left unaddressed it can cascade into anxiety, depression, and even anger.
Finally, it’s important to recognize that cancer-driven mental health issues can impact the very relationships patients rely on for emotional support. Feelings of guilt, despondence, detachment and even shame can take control of a patient’s internal dialogue and create distance between them and their loved ones. Again, the emotions aren’t always rational. But when someone is sick, or treatment has taken a toll on their appearance and/or stamina, it is easy to fall into an emotional hole that can overwhelm personal relationships.
Early Attention is Key
It is vital that mental health issues be assessed and addressed as early as possible in a patient’s care plan. Symptoms are not always obvious. The patient who is upbeat and positive at the clinic may be falling apart as soon as they are alone. Or the patient who starts treatment determined to beat their cancer can, over time, become hopeless or overwhelmed.
If patients in need are not given the resources to manage the internal dialogues pecking away at their emotional fortitude, it can have a domino effect that impacts treatment outcomes, long-term health and wellness, and the interpersonal relationships they need in the battle for their lives.
To make that happen, the patient’s clinical team can look for signs that they may be struggling. They can also integrate mental health assessments into their standard practice, approaching it in the same manner they do other health issues – straight forward and empathetic and without judgement. It can be as simple as inquiring if the patient is okay or letting them know it is normal and okay to not be okay – and that resources are available to help them manage their mental health in the same way resources are available to help them manage pain or nutritional needs.
At American Oncology Network (AON), those resources now include credentialled behavioral health therapists to whom patients can be referred for additional assessment and, if needed, a therapy program tailored to their unique needs. Therapists are currently available to practices in Arkansas and will soon be available in Iowa, Missouri, Louisiana, and Indiana. The Behavioral Health Team is growing, with the goal of having credentialled, licensed therapists available to patients in every state where AON has partner practices.
The Mind-Body Connection
Helping a patient with their mental health struggles can be as simple as having someone that is not on their medical care team or in their family or circle of friends who will listen to and reassure them that their thoughts and feelings are normal and understandable; someone who can give them the tools to cope with what they’re experiencing. In some cases, a patient may only require a few sessions for them to feel emotionally stronger. In other cases, more intense or longer-term therapy may be necessary, such as when a pre-existing disorder has been triggered by their diagnosis. What is important is getting the patient the support they need before it spirals out of control.
There is a strong connection between the mind and body. What impacts one will almost always impact the other. For cancer patients struggling with mental health issues, helping them get to an emotionally healthy place can change their entire outlook and empower them to withstand the many challenges they will face whatever their outcome might be.
Holistic cancer care is enjoying growing popularity as the body of evidence on the benefits of treating the whole patient – the physical, emotional, and socioeconomic aspects – increases. Yet nutritional support is often overlooked in otherwise comprehensive treatment plans. It’s an oversight that can exacerbate side effects, prolong or delay treatment, and complicate short- and long-term recovery.
That is why American Oncology Network (AON) has assembled a team of highly qualified and credentialed oncology dietitians to work with its community practices on ways to integrate personalized nutrition counseling into care plans. While the program is still in its infancy, early response has been positive as patients and clinicians alike see first-hand how proper nutrition and in particular prevention of malnutrition is creating a solid foundation for successful treatment.
Why Nutrition Matters
Proper nutrition plays a vital role in how well a cancer patient responds to treatment. Not only does nutrition impact energy and stamina levels, but it can help boost the body’s response to treatment and therefore the efficacy of prescribed therapies.
An important goal of oncology nutrition is preventing a patient from becoming malnourished – which is much easier than treating malnutrition. When a patient maintains a healthy nutritional status, they are typically able to handle treatment much better. They don’t need to pause treatment or change treatment plans due to weight loss or the body’s inability to tolerate the full course. Thus, the ability to maintain a base level of nutrition from the outset of treatment sets the patient up for success and helps drive better outcomes.
Maintaining healthy eating habits can also give patients an emotional boost, especially when side effects from treatment sap their appetite or make eating a struggle, for example due to appetite changes, nausea, fatigue, or changes in how things taste or smell. By reframing how they view food into something with purpose, for example as fuel to power the body through treatment rather than simply an act to be performed, can help patients overcome some of the mental challenges which can be particularly helpful when eating is the last thing someone wants to do.
Nutrition – and nutrition counseling – can also help prevent patients from developing an unhealthy relationship with food. A handful of studies have found a relationship between a cancer diagnosis and development of an eating disorder like orthorexia, which is an obsession or fixation with “proper” eating to the point it becomes unhealthy. One theory is that patients fixate on food and nutrition to regain some of the control that cancer has taken away. Others suggest that controlling food intake becomes a way of subconsciously punishing their bodies for getting sick in the first place.
Working with oncology dietitians can help maintain a healthy nutritional status by identifying the right foods to fuel patients’ bodies. It also helps them maintain a healthy relationship with food, nutrition, and their bodies as they battle cancer.
Food for Wellness
When it comes to healthy choices from both a prevention and treatment standpoint, variety is the key, as is understanding how nutritional needs evolve over time for many patients. In general, the ideal diet for optimal nutrition consists of a wide variety of nutrient dense foods. These are typically plant-based – foods that are grown and eaten in their natural state such as vegetables, whole grains, beans, nuts, and seeds. However, during treatment or recovery, food priorities may shift to focus on adequate calorie or protein intake to promote maintenance of lean body mass and/or weight.
Along with variety and flexibility, another good rule of thumb is to eat the rainbow. Consuming foods that encompass a wide range of bright colors is an easy way to ensure the body is getting a variety of antioxidants and phytochemicals. These components also work together synergistically to help support overall health and wellness.
Adding protein to the mix supports lean body mass and muscle stores and adds calories – all of which are particularly important for patients who are undergoing treatment. Nutritional needs should be assessed periodically to ensure they are being met, and adjustments made as patients transition through treatment and into recovery.
An Important Focus
AON understands the importance of proper nutrition for cancer patients. That is why every member of its nutrition team is a Board Certified Specialist in Oncology Nutrition (CSO), a credential that was developed by the Oncology Nutrition Dietetic Practice Group together with the Commission on Dietetic Registration. A recommended minimum of two years of clinical practice with documentation of 2,000 hours of practice experience in the oncology care setting is required to sit for the certification exam – which must be retaken every five years to remain certified.
CSOs and oncology nutrition are important additions to the holistic care model used by AON’s community-based practices. A cancer diagnosis is traumatic, and treatment can be grueling. But a whole-person care plan that includes nutrition counseling can put the patient on the path to the most successful outcome possible.