The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Sibley Memorial Hospital, Washington, DC, provides a wide range of healthcare services to the area’s communities. Through integrated care with other Johns Hopkins locations, the center’s healthcare team has access to novel treatments and resources to assist in developing and delivering individualized cancer care to patients.
In this issue of The Oncology Nurse-APN/PA (TON), we feature an interview with Marissa Panzer, DNP, AGNP-BC, who discusses her roles and responsibilities at the center, as well as her team’s approach to providing safe and effective care to patients during the ongoing COVID-19 health crisis.
Dr Panzer: I am a clinical partner with one neuro-oncologist at the center. We see patients in a collaborative partnership, which allows for seamless management in their ongoing care. Symptom management is a major part of my current responsibilities. I conduct a specific 1-hour meeting with each patient to go over goals of care and to revisit these goals when circumstances change, such as if a patient’s condition worsens, we are running out of treatment options, or we think more treatment would not be beneficial in terms of quality of life.
These goals-of-care discussions are unique to my role as part of a team that treats patients with central nervous system (CNS) tumors. They open the door to talking about prognosis as it relates to the specific tumor type and advance directives. I strongly believe that we need to normalize discussions about advance directives.
I am also responsible for conducting transition visits with patients once they have completed chemoradiation. During these visits, I explain the next steps in their care and treatment, which offers additional support to patients and their families.
Dr Panzer: Before the pandemic occurred, I would see all new patients and follow-ups in person with my physician partner. When I was new to neuro-oncology, this was a great way of learning how to discuss the patient’s diagnosis and plan of care, and we were able to conduct a full head-to-toe neurologic examination.
When a patient is diagnosed with a brain tumor, it can be difficult to digest all the information. So, typically, 1 week after the initial appointment, we would schedule a chemotherapy education appointment and goals-of-care discussion. At the end of chemoradiation, we would then revisit the rest of the treatment plan with the patient.
Post-pandemic, we utilize telemedicine whenever possible. Although it is more difficult to examine patients, and obviously, we cannot assess reflexes or sensory responses remotely, we can still gather a lot of information. Patients are still able to come to the center for in-person appointments if necessary.
Fortunately, our department had started a telemedicine pilot program prior to the pandemic, so we were ready to use this technology when it became necessary. Telemedicine is working well for our patients. We are able to see individuals who are bedbound, or who otherwise could not get here. In addition, it has allowed the patient’s family members to be part of the appointments when appropriate.
Although I have not been able to see new patients with my physician partner in person since the pandemic began, I do have in-person visits with patients who are already at the center for chemoradiation. We are trying to limit the number of individuals who are seen in a room to decrease the risk of exposure to the virus. Our medical oncology unit has also set limits on visitors.
I also see patients independently. The more you are on track with your patients, the easier it is to plan for the future. Our neuro-oncology team, which includes many other team members, such as radiation oncology professionals, meets weekly to discuss patients. My physician partner and I keep in close communication several times a week.
Dr Panzer: Before the COVID-19 pandemic occurred, my biggest challenge was learning as much as I could about neurology and neuro-oncology. I needed to understand how a tumor’s location affects an individual’s function. Now that I have been doing this for almost 2 years, I have more confidence. However, there is always something new to learn. The challenge is discerning which symptoms are caused by the tumor and understanding those associations.
Another major challenge is making sure that patients and families feel comfortable with the plan of care. Some patients with CNS tumors have deficits that may make it difficult to understand information. It is very important that we assure patients and their families that we are here to support them.
It is also challenging to see so many patients who have a poor prognosis. I do whatever is in my power to help them, but I know their time is often limited. I want to make sure that the time that they have left is quality time. We encourage patients to do things that are enjoyable, including seeing family and friends through Zoom calls or outdoor gatherings, while taking the precautions that make sure these visits are safe.
It is rewarding to see patients improve or to see them participate in important life events, including milestones such as having a child, getting engaged and married, taking trips they have always wanted to take, and holding a grandchild. I ask them to send me photos, and I encourage them to enjoy life as much as they can.
Dr Panzer: All patients with cancer need physical and emotional support, but brain tumors are especially frightening for patients, especially if the tumor cannot be surgically resected. The anxiety that comes with a diagnosis of a brain tumor is unique. Most individuals are familiar with warnings about breast cancer and colon cancer and the need for screening, but they are not prepared for a diagnosis of a brain tumor. There are no screening tests and there is no effective prevention strategy.
The symptoms that accompany CNS tumors, such as seizures, headache, and other neurologic symptoms, are frightening to patients and difficult to manage. There is no way to prepare for waking up one day and discovering that you cannot use your right arm, or that you cannot verbalize your thoughts properly.
Dr Panzer: After I completed nursing school, I became an emergency department nurse. However, I quickly discovered that this was not my calling, so I started researching other possibilities. I was influenced in part by my experience with my mother when she was diagnosed with breast cancer and then became a survivor. She always said how important it was to have nurses who treated her well.
As a nurse, I had no other experience with cancer, so I applied for a position at the same facility where my mother was treated and was hired as a triage and infusion nurse. I transferred to Sibley Kimmel Comprehensive Cancer Center as an infusion nurse, and then applied for a graduate program. I knew it would take a long time to complete the program, but I love to learn. I was in school full-time and worked part-time for many years. I earned my Doctor of Nursing Practice degree and returned to oncology, which is where I felt I belonged.
Dr Panzer: I enjoy learning about new treatments and the science behind them. Of course, I am interested in research that relates to CNS tumors. Currently, I treat patients with glioblastoma and more common brain tumors, so I am excited about studies evaluating drugs that can break through the blood–brain barrier. Not many chemotherapies can cross that barrier, which is a major hurdle in treating CNS tumors. If we can solve this problem, it could open a world of possibilities.
There is exciting data showing how some medications target the IDH gene mutation, which is present in a small percentage of patients with glioblastoma and approximately 70% of those with low-grade brain tumors. If we can repurpose IDH inhibitors used in acute myeloid leukemia that cross the blood–brain barrier, it would be an incredible advance.
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