Cancer Care Delivery Across Practice Settings: Michi Gray, RN, and Joscelyn Vanduren, ANP

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today, we're here at ONS Congress, and I'm joined by Michi Gray and Joscelyn Vanduren. Thank you both so much for coming on today.

Michele "Michi" Gray, RN: Thank you so much.

Joscelyn Vanduren, ANP: Thank you.

Oncology Data Advisor: Would you both like to introduce yourselves and share a little bit about what you do?

Ms. Gray: My name is Michi Gray, and I am a Radiation Oncology Nurse Care Coordinator at the Cleveland Clinic. I've been an oncology nurse for 23 years, the last eight years being in radiation oncology.

Ms. Vanduren: My name is Joscelyn Vanduren. I'm a Nurse Practitioner in Anchorage, Alaska with Advanced Oncology Associates. I've been a nurse practitioner for a long time—11 years—and in radiation oncology for six of them.

Oncology Data Advisor: Great. You both presented this morning a session entitled Misconceptions in Care Delivery: Patient Outcomes Between Practice Settings. So, what are some of the biggest drivers behind these differing outcomes between urban versus rural settings?

Ms. Vanduren: They have a lot of similar problems. It's just on the scale, transportation seems to be a big factor, regardless of where you're at. Some transportation is a little bit harder, just being able to have planes and whatnot and whether or not that affects them. Ability to deliver care is affected by not being able to have the machines and the technology available. Most rural places do have some sort of technology. It's just whether it is the newest or the greatest, and then having the staffed resources to be able to run those machines is a big thing.

Ms. Gray: Absolutely. I agree with that. As far as resources, it's the transportation, it's the knowledge and education. There are so many things, social, economic, insurance. So, there are many things, as Joscelyn said, that share a lot of this between the urban and the rural. We see the differences in the disparities when you get to a rural setting; it does become a little broader. It becomes a little harder for the rural people to get to the resources; the knowledge base sometimes, the education level, may or may not be there. Then again, in the urban setting, in the minority areas within the urban setting, it can be the same. It can be similar to those rural areas. So, we look at it as, yes, it is an urban setting, but they still have some of the same disparities as out in the rural areas.

Oncology Data Advisor: Do these differences manifest in terms of treatment selection and outcomes?

Ms. Vanduren: I think a lot of times with the rural areas, people coming from further away, they want the shortest possible treatment they can have. So, they try and push, and they say, "No, I don't want maybe the standard of care, I want to go with radiation, a hypofractionated course," even though it might not be the best option for them, but they don't want to be away from home for so long. So, I feel like sometimes those kind of things are driving factors regardless of what we want as providers and nurses. Sometimes the patient has the ultimate decision and they're allowed to make whatever decision it is. We just have to make sure that they know what's available for them.

Ms. Gray: Absolutely. Yes. They do just make decisions. Many times, I know with the Cleveland Clinic, our physicians will give them options and they will take that into consideration—transportation, for example. They will do one, three, or five treatments of radiation, such as stereotactic body radiation therapy (SBRT), given the option. It's like, "Okay, you may have a bigger side effect profile. You may have more side effects if we do the same treatment in one fraction than you would if we were to break this up in five treatments, but we understand it may be difficult for you to come five times to drive this distance. So, we're willing to do it". The outcome will be the same or similar within 1% to 2% difference. But this is something that we're willing to discuss and talk to you about and do that.

Oncology Data Advisor: Great. Knowing these disparities, how can nurses keep them in mind and apply it when they're talking to and educating their patients?

Ms. Gray: I think this is one of the things that I really got a little passionate about in my talk. Transportation—when the nurses are in front of the patient, that is one thing that we can truly listen to the patient and find out. And it's not just transportation, but anything really. We don't need to ask the close-ended questions, asking the yeses or nos.

When we're asking the questions about what their issues are with coming to treatment, we need to really ask open-ended questions, ask what are the issues, really dive into what are the barriers, and then try to find the resources. Nurses may not be solving it. We may be then reaching out to our social workers to help with that, but getting those answers. For example, with transportation, if we say, "Do you have transportation issues?" "Yes." Oh, they can't come for treatment here. They have to go locally. Instead, it's like, "Oh, well, what do you feel your transportation issues are? Do you have somebody to bring you? Do you need a driver? Do you have a car? Do you need gas money? Is this a financial issue?"

We have gas cards we can give patients. We have a van service that can pick up patients and bring them within a 25-mile radius to treatments. So, we have options. We can house patients. So, anybody that lives beyond that 25-mile radius, we can actually house them. Or, if they live beyond an hour and a half or an hour, we can house them for free. If they live closer than or further than that—I can't remember, there's all the criteria the social workers know that I don't know. But there are low-cost places that are anywhere from $33 a night—so, free or $33 a night, then even the nicer hotels give a discount at Cleveland Clinic rate. So, there are options. The social workers are great. So, it's just really asking, "What are the barriers?" not finding out just yes, no, yes, no, on some questionnaire that they're given when they come in. But that's something the nurses can do, getting those answers and not just going through a checklist.

Ms. Vanduren: Totally agree. Again, if they have transportation there, do they have housing while they're there, do they need that? What about, will they be able to get their meals and stuff once they get there? That's a big thing.

What happens if they can't take care of themselves? Do they have a medical escort or a family member that can come with them and can that person actually stay there and those kind of things? Or is it not any transportation issues with that person, but what about their escort and their escort actually physically being able to stay there and having that time off too? So, those are big things.

Oncology Data Advisor: Great. Well, this is really important advice, so thank you both so much for talking about it today.

Ms. Gray: Thank you.

Ms. Vanduren: Thank you.

About Ms. Gray

Michele "Michi" Gray is a Radiation Oncology Nurse Care Coordinator at the Cleveland Clinic, and she serves on the Cleveland ONS Chapter as a Director at Large. In addition to being passionate about radiation oncology and patient advocacy, Ms. Gray has developed a passion for medical missionary work as well, having traveled to places such as El Salvador and Honduras up to 10 times to provide care to underserved individuals in those countries.

About Ms. Vanduren

Joscelyn Vanduren is a Family Nurse Practitioner in Anchorage, Alaska with Advanced Oncology Associates, where she works with patients from all over the state of Alaska. Ms. Vanduren specializes in patient care, coordination in patient care, and symptom and toxicity management. As well, she is passionate about patient advocacy and accessibility.

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Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.