Advanced Practice Providers – APPs 101: Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNS) in Oncology

"There are different types of advanced practice providers that you may meet in an oncology practice - PAs, APRNs, NPs, but what’s the difference between them? In the second episode of ASCO Education’s podcast series on Advanced Practice Providers (APPs), co-hosts Todd Pickard (MD Anderson Cancer Center) and Dr. Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guest speakers, Leslie Hinds (Centura Health), Martin Clarke (Arizona Oncology), and Kathleen Sacharian (Main Line Health), break down the differences and similarities between physician assistants and advanced practice registered nurses, share what their days might entail in each of these roles in an oncology practice, as well as address some common misconceptions surrounding these types of APPs. Duration 35:52. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at [email protected]."   TRANSCRIPT Dr. Stephanie Williams: Hello and welcome to ASCO Education's Podcast Series Advanced Practice Providers, APP 101: Physician Assistants and Advanced Practice Registered Nurses in Oncology. I am your co-host, Dr. Stephanie Williams, with physician assistant, Todd Pickard. Today, we are joined by Leslie Hinds and Kathleen Sacharian, both of whom are nurse practitioners, along with physician assistant, Marty Clarke. All three of today's guests are a part of the APP Task Force. Thank you all for being on our panel today. Leslie, Kathleen, and Marty, could you please tell our audience a little bit about yourselves, starting with you, Leslie? Leslie Hinds: Good morning! I am a nurse practitioner in the Denver, Colorado area and I am in community practice. Kathleen Sacharian: Good morning, everybody! I'm Kathleen Sacharian, and I'm an oncology nurse practitioner. I've had over 20 years of experience in both academics setting and community practices in the Philadelphia area. Marty Clarke: Hello, everyone! I'm Marty Clarke. I'm in Tucson, Arizona. I've got closer to 30 years of practice in general medical oncology, as well as a fairly lengthy stint in cancer psychiatry. I'm also a clinical psychologist. Dr. Stephanie Williams: Thank you all. Today's episode will be a deeper dive into the specifics of what physician assistants and advanced practice registered nurses or nurse practitioners do on a day-to-day basis in an oncology practice, as well as addressing some common misconceptions of what PAs, APRNs,  NPs do in practice. So, jumping right in, I'd like to ask you all to shed some light on the general differences between a physician assistant and an advanced practice registered nurse or nurse practitioner. Who would like to start? Todd Pickard: I'll get the ball rolling. This is Todd. This is a great question. It's one that people ask a lot, you know, what is the difference? And honestly, in the clinical setting, there really is no difference. When you see an advanced practice provider, whether they be an APRN or a PA, you're going to get the same kind of team-based care with quality and safety and that really focuses on the totality of the patient. PAs and NPs arrive to their clinical work from different educational perspectives. But the work we do really is the same high-quality level of care. I'll defer to my colleagues to add some to that conversation. Leslie Hinds: Yeah, I would agree with you, Todd, that in practice, NPs and PAs provide the same quality of care and the same type of care but our education and background is oftentimes different from a nursing role versus a medical role. Kathleen Sacharian: I'll add that, you know, I think when we think about some of the main differences, really focusing, as Leslie said, like how are we prepared? How are we trained? A nurse practitioner is typically a registered nurse with a bachelor's degree and then goes back for a graduate degree in either a Master of Science in Nursing or a Doctorate in Nursing Practice. And typically, some of the main educational differences in a nurse practitioner role are that their focus in education is population-based, meaning it's based on a specific patient population or health condition. So, you might have an adult gerontology nurse practitioner or a pediatric nurse practitioner. Marty Clarke: Kathleen, I have a daughter that happens to be a GYN oncology nurse practitioner. And so, her focus is a little different than mine but it's always fun when she reminds me how much smarter she is in certain areas. Dr. Stephanie Williams: Just from my standpoint as a poor old physician here, are there differences from state to state between what you guys can do? That’s one question. Two, your histories are so different in terms of how you came to become PAs, how the field of PAs and how the field of nurse practitioners developed, which is, in my opinion, very fascinating. So, I wonder if there are any comments on any of those issues? Todd Pickard: Yes, Stephanie. That's a great question. I was just thinking about how really, when people see differences between APRNs and PAs, it's generally because of state law or an institutional policy. And that's what's very unique about advanced practice providers is that their practice can vary wildly from state to state, unlike physicians, who basically have one standard national type of practice. An APP in Texas looks very different than an APP in New York or Alaska or Hawaii or Mississippi. And so, you do have to be very cognizant of the fact that it is important to be aware of what each state says or what even individual institutions say. Leslie Hinds: At my institution, physician assistants are not allowed to supervise infusion, which is a big part of medical oncology. So, unfortunately, in my practice, we have nurse practitioners only and have been unable to hire PAs because of that limitation. Dr. Stephanie Williams: So, these institutional guidelines, are they based on state regulations or just based on current practices at those institutions? Kathleen Sacharian: Well, I think it's really dependent on the institutional experience, you know, there might be a large academic center that has a very well-developed advanced practice provider program compared to maybe a smaller community practice that has one nurse practitioner or PA. So, I think the experience with the individual institution or clinic, but overall, that really is dictated by the state licensure and regulations. So, that is the first thing that needs to be looked at when considering these roles and responsibilities of advanced practice providers. Todd Pickard: Stephanie, you bring up a very good point, which is whenever an institution or an individual practice takes a position, it's always good to explore the 'why'. Is this customary? Is it a habit we've been in? Or is it based simply on a misunderstanding or even a preference? Many times, when you go to explore these things, you'll find that it's either a misunderstanding or a preference. It's not because something is required that way. At my institution, for the longest time, we only hired nurse practitioners on the inpatient side, because somebody thought that PAs didn't learn how to take care of patients in the hospital. And we had to have a conversation. I said, “No, actually, when I was in PA school, I actually had to sleep in the hospital, and for 6 weeks on my inpatient medicine rotation, so that I could give care 24 hours a day.” So, no, we are trained there. So, it was completely a misunderstanding. And so, I think that's why it's very important that you have advanced practice providers who are part of your leadership in your governance, so they can help you craft good practices, good policies, top of license practice so that you really maximize all the team members. Marty Clarke: All these points are really poignant. The example of PAs not being able to oversee infusions, that probably stems out of an assumption that PAs, unlike oncology nurses that then become NPs, are more qualified somehow for infusion. And it goes back, I think, to what we talked a little bit about the training, where PAs are trained in the medical model. There are assumptions that are made around that that sometimes are not correct, just as the nurses are trained under nursing theory. And there are assumptions that are made around that. In my practice, there's a belief that the nurses can't function in the hospital, which is, you know, kind of ironic to me. And I think it's an assumption based on their training and an incorrect assumption. So, again, Todd, you're right. You need leadership and an open mind to this and also, you've got to pay close attention to what the individual, you know, state laws are, but they're more similar than they are different, I would say. Dr. Stephanie Williams: Just as a for instance, guys, I practiced for several years in the state of Michigan, the law has changed now, thankfully, but I had a combination of nurse practitioners and physician assistants, and my nurse practitioner, by law, could not order a consult for physical therapy, only my physician assistants can. So, I think it gets frustrating for physicians, because then how do I know what a PA can do and what an NP can do if, you know, I go to Illinois now and I practice under a different set of state laws. When I started in my career over 30 years ago, PAs were quote, “surgical”, they held retractors, they stitched people up, they did our urology consults for instance and put Foleys in. And nurse practitioners were more bedside, taking care of patients. I think some of that has changed. But I don't know if you guys have any comments, how does a physician who's in practice in the rural community, and a more cosmopolitan community and academia, how do these things differ in your daily day-to-day routines? Todd Pickard: This is a great transition, you know, Stephanie, that's a very salient point, is really to take a little bit of a deeper dive into thinking about how PAs and APRNs are trained. So, Marty, we’ll get you to say a little more about PAs, and then Kathleen and Leslie a little bit more about the APRNs. But generally speaking, PAs attend schools which are generally housed in medical schools. And so, we share the same faculty, we rotate with the medical students, sometimes we take the same courses as the medical students, and we're really trained in that medical model, which is basically a little bit of everything, the same thing as medical students. And one thing that we have included in our training, which is different than nurse practitioners and APRNs, generally speaking, is we have surgical training, not to say that APRNs cannot be in the OR, they do some extra training as an RN first assist certification for that type of role. But for PAs, that's just simply built into our training. And the reason that PAs are trained in this way is, you know, because we have our background in the military. In the military, we were part of the medical units. We were field medics. And then, after folks started coming back from their military service, they realized there really wasn't any civilian role for those highly trained folks. So, some physicians at Duke University created the PA profession. And of course, they built it to work alongside physicians. So, they taught them the only way that they know how, which is the medical model, which is how they were trained, and it's interesting that PAs and nurse practitioners were born in the same year, 1965, but just in two different parts of the country. So, Leslie, Kathleen, tell us a little bit more about the training that you receive, and why does the population model matter? Kathleen Sacharian: So, I'd say when you think about the nurse practitioner, you know, typically, and not always, but a lot of times, they'll have some registered nursing experience. And then, they decide to go back for an Advanced Practice degree. They choose a specialty based on interests, so that might be Adult-Gerontology or a Pediatric focus. So, we're really focused and trained clinicals, you know, all of that training is really built around that population focus. So, once you graduate, national certification, and licensure is then required. It really then takes on what happens next of roles and responsibilities, I think really goes into the training, the onboarding, and training of the provider, is a lot of times, you know, built into that on-the-job training. There might be fellowships that the nurse practitioner is a part of. For example, there’s a lot of new oncology fellowships that are coming out for advanced practice providers, which really gives them a good additional focused training to be able to be ready to provide that advanced practice care for oncology patients. Leslie, I don't know if you have anything to add to that. Leslie Hinds: Yeah, I agree with the background and the education. you know, there are a lot of different specialties that you can graduate with an Advanced Practice Nursing degree, and I completely agree that most of the education for practice is learned after graduation. And then, you learn the specialty that you're interested in, or family practice, whatever you choose to do, but the education that you receive after graduation is mainly affecting your practice. Marty Clarke: Leslie, I really agree with what you were saying about, regardless of your training model, what really happens in my experience working with PAs and NPs is that you develop a way of practicing that is consistent and congruent with how the team that you're on practices, whether it's just you and a physician, that's a team, and you develop a pattern of practice that is complementary. And I think that both PAs and NPs, at least in my experience, are able to make those adjustments on the fly, really. Having said that, there are times that I'll have questions about a patient I'm seeing. And in my practice, I can go to a PA or to an NP, and there are times that I'll go to one of the NPs because they have a just a little different flavor, a little different take on something that I think might help me sort things out a little better. Other times, I'll choose to go to a PA because I know that their training is going to lend itself to kind of my way of thinking. The medical model piece is to me an advantage and a disadvantage, and here's how I mean that. One of the things I tell the oncologists I work with, when they're looking for us to see a certain number of patients in a certain period of time, they're operating out of their experience. And because of their training, they can see to the bottom of the bucket faster than I can, and faster than any of my peers can be it PAs or NPs. So, I'm constantly reminding the oncologist one of the things that we all bring to the table as APPs is a little more time with the patient. But the medical model sort of is focused on the biological, the pathological aspects of what's going on with the patient. The personhood often becomes after that. And that's sometimes why I'll go to an NP because a lot of times that personhood is closer to the surface with them. So, my personal experience with the medical model, when I applied to get into the clinical psychology program, I was told, “We can't let you in this program because you've been taught in a medical model, you think in a medical model, and you'll never unlearn that enough to be a good psychologist.” And I had to beg and plead with them for an opportunity to prove them wrong. And fortunately, I guess I said something that allowed me to do that, but they were right, it was a very, very difficult task and challenge. To me, the medical model is, you kind of, is a little bit like being a Marine, you sort of go for the meat pretty quickly, and there's sometimes some finesse and some touch that's lost in that. And other times, it's really great. You know, it's exactly what's needed. Todd Pickard: Marty, you have said so many profound things in such a small amount of time that I'd like us to take a little bit of time to unpack that. And so, one of the things that you really clicked on, and Leslie and Kathleen also did this, was the concept of, we all come with our educational backgrounds with a certain foundation of knowledge, and we build upon that as advanced practice providers in our team-based care and our partnerships with our physician colleagues. Any physician can trust that a new grad APP is going to know how to do a history, a physical, manage basic issues around a patient's symptomatology, and that they're not going to let patients get harmed. We know that much. But the things that we have to learn are the specifics to the practice that we're in, whether it be lymphoma, leukemia, stem cell transplant, breast medical oncology, GI medical oncology, whatever it is. And so, that's critically important that when you have an APP that comes to the table with that foundation, and then build from there, unless they've worked in that same specialty before. One other thing that Marty said that was really important, I think, is that we all, whether we're APPs or physicians, really have to recognize that we treat whole human beings, not just the cancer cells in their body. And so, I think that's a mindset that has changed significantly over time. I mean, I went to my medical training in 1990, and, you know,  as an educator and as somebody who works with trainees now, I know that that approach is different because people think about the social networks, the support that folks have around that, their own mental health, can they comply with medication orders? Can they get to their appointments? Do they have resources? So, we're really thinking outside of that box. And I think another thing that you said, Marty, that is so interesting to me is why do people focus on so many misconceptions in medicine? ‘Well, you can’t X because you're a Z.’ That makes no sense to me. And for some reason, we spend a lot of time, I'll just say what I think it is, with these turf battles, 'don't play in my sandbox, go be in your sandbox'. And so, I think that's the thing that APPs are really committed to. We want to play in all the sand boxes because our focus is on the patient, not whose turf we're on. So, Leslie, Kathleen, Marty, what do you think about that kind of team-based approach and why does that matter to advance practice? What does it mean? Because I feel like it's in all of our DNA because that's how I grew up as an APP. What are your comments on that? Kathleen Sacharian: I completely agree with both of you. I think it’s just the importance of how we work together. Our patients are at the center of all of our goals, right? Our outcomes are to improve patient care and provide them the quality of care that they deserve. And that takes a village, that takes the entire team from the oncology nurse to the PA, to the physician, to the nurse practitioner, you know, it really takes all of us to be able to provide that care that they need. And that's, you know, knowing when to say I need help, right? Who to ask that question to, using your resources. I also think like not making any assumptions. Don't assume that because a nurse practitioner has been an oncology nurse for 20 years that she's ready to go, and to be able to provide that advanced practice care. She's going to need that support and training. So, I think just not making any assumptions and just really being open-minded and working as a team is just critically important to providing that patient care. Leslie Hinds: Yeah, I agree with that. And I do think going more on the assumption of a nurse practitioner coming into practice: if they have oncology experience as a nurse, and they've been working as a nurse for a long time, there can be challenges with the change of the mindset between the roles between a nurse and nurse practitioner. And I think that that is underestimated by a lot of physicians or other practices and just assuming that this nurse has a lot of experience as a nurse, so they're going to transition to this role easily. And in my experience, that is not the case, and oftentimes, the nurse practitioners that I've trained that are coming in with a lot of nursing experience are much more difficult to train to be a nurse practitioners with that mindset of an advanced practice provider. Kathleen Sacharian: I don't want to negate that experience. I think that oncology nurse experience is invaluable for how they treat the patient, how they take care of them, how they assess the patient. And just bringing that experience to practice is incredibly invaluable. But just recognizing that difference between an advanced practice role and a registered nurse role is just important to consider. Marty Clarke: Yeah, and I'll add to that for what it's worth, all of us work in a very demanding environment and the brain is designed to be as conservative as possible in its energy consumption. So, it takes shortcuts, cognitive shortcuts, it makes up answers to questions, sometimes whether the answers are correct or not are not important. So, that's how assumptions I think get played out. And Leslie brought up a good sort of assumption that sometimes physicians will make about a nurse practitioner that, 'Well, they were an oncology nurse so I'm going to have them just kind of do more of that sort of thing and a little less of what I would be doing', going back to the sandbox sort of analogy. And it's really just almost a reflex. But if we can be aware of that and train our physician partners that that may be a tendency they have to think of us in a constricted way because that's cognitively easier. It's what keeps us often from practicing to the full extent of our capability and our license. Dr. Stephanie Williams: Todd, can I just say one thing from a physician standpoint? I mean, this is great and I agree with everything. You know, there are still physicians who think that an APP is an extension of me, and you do what I tell you to do so that you can make my life easier. That's not where the focus should be. The focus should be on that patient sitting there in front of you, and how can we make their life easier. How can we all work together in the sandbox. Marty, our psychologist, was going through our brains and how they function. How can we work together to better the care of that patient, and the care of ourselves? We have to help prevent ourselves from burning out. How do we change that focus? There are still many physicians, unfortunately, out there who want you just to be there for them, instead of being there for the patient. How do we change that? Todd Pickard: Stephanie, that is a profound question. I think that it is one that takes a lot of thought individually because what I think is at heart here, you know, the heart of the matter is that folks are so focused on surviving day to day. They think of the tools that they can use that make their life easier. I think what we're all saying is that we need to flip that around and think of who are the partners on my team that help me care for the patient, and we do our work together. So, if you approach it from the mindset of 'this is all my work and what are the resources that will help me complete my work', then you don't think of partnerships in teams. You think of people who do the work the way you want the work to be done and it's all about you. When you flip that and you really embrace the power of the team, what it is a group of folks who are all sharing the burden, and who will make sure that the patient, instead of the work, the patient is cared for, and all the services and all the things that the patient needs are done by the right people. And so, it's not about my work. It's about our work. And so, I think there are highly-functioning teams out there and they've really embraced that concept. But Stephanie, you're absolutely right. There is a model that there is 'physician work', and everybody around the physician is there to help the physician. But I do think that that is changing because we really are looking at how folks work in teams. So, I'd be interested to hear how, you know, Kathleen and Leslie, and Marty, think about this whole 'my work' versus 'our work' and what are they experiencing. Kathleen Sacharian: Well, I would add to that I do agree, again with that patient-focused and patient-centered care being everybody's outcome and goal. But what does that look like in day-to-day and when talking about burnout, you know, you think if you're just being delegated all of the really difficult tasks or, you know, the things that people don't want to do, that certainly can lead to burnout. I think we need to maximize people's interests, people's focus, and specialty. Maybe it's a procedural. You know, maybe the PA or nurse practitioner really enjoys doing procedures or doing consults. There are so many specific examples of those roles and responsibilities of how they can, you know, take some of the burdens of day-to-day patient care and maximize them based on patient interests, specialty, and again, with that overall outcome of just improving the care and being efficient, and providing that quality of care. But really like identifying, talking, as a team working through it, have quarterly meetings about what's working in your practice, what's not working, and how we can improve this, using your resources, too. I think there are a lot of great resources out there that can help to educate the teams about best practices in a team-based model. Leslie Hinds: Yeah, I agree, team-based care is definitely best for the patient and whole patient care, and there are definitely still barriers out there that we deal with on a day-to-day basis that are coming in between team-based care. And I really believe that is to the detriment of the patients. You know, I think there should be more education for physicians on how to work together as a team, instead of working together just as, 'you are my servants so you're going to do what I want you to do', and not allowing the team around them to practice to the top of their license, and ability, and interest. Marty Clarke: Yeah, I think this real a, really important subject that needs a great deal of exploration and education across the board. My way of thinking about it is everybody has a little bit of magic and sometimes we're not able to figure out what our magic is because we're forced or pigeonholed into a certain role, but allowing every participant on the team to sort of find out what they learn, figure out, and sort out, what their magic is and to be able to bring that to the table. You know like what Kathleen was saying, that's what keeps people engaged and what keeps them motivated. When I grew up, the term was 'scutwork' you know. I was taught 'a pound of scut for a pound of teaching', but we all have to do work we don't particularly enjoy, and that has to be rewarded by allowing us to do something we really do enjoy. And when we do that, we bring some energy to the patient and to the team. That's when synergy starts happening. But that's not, going back to what we said earlier, that's not how the medical model, it doesn't start from that position. That's what we have to, over time needs to be I think re-engineered a little bit. Dr. Stephanie Williams: Leslie, can you give us an idea of what your day is like? Leslie Hinds: Sure! So, for the most part, I'm in the clinic, but we have patients who are admitted then oftentimes they do go to the hospital to see them and then run back to the clinic to see my scheduled patients for office visits. A lot of my time is spent answering questions from the infusion nurses, from the MAs, and from patient calls coming in. We do procedures, so, bone marrow biopsies, Ommaya infusions if needed, and another good portion of my time is spent analyzing results as they come in. The sheer volume of the inbox and the results of it coming in is quite overwhelming sometimes. But, you know, taking the time to analyze results that we're hoping not to see, like a positive scan, and then developing an evidence-based plan for what to do next to help manage these patients appropriately - that's time-consuming. I do a lot of patient education. And also, manage a lot of emergencies that happen during the infusion. So, we basically manage the infusion center and see patients and answer questions. So, that's mostly my day. Dr. Stephanie Williams: Thank you! Kathleen, how about you? What's your day like? Kathleen Sacharian: Well, it depends. You know, I've been in outpatient, it looks very different from inpatient, and the outpatient experience really looks very similar to Leslie's treatment visits, seeing follow-up patients, they might be a longer-term follow-up, providing symptom management, working with our triage nurses to, you know, escalate significant problems, or treating them at home, providing that emergency and infusion-related care. But I think there's also to think about part of my role was developing a patient-specific clinic for survivorship patients. So, my role when I was a survivorship nurse practitioner was very different. I was providing program development. I was seeing patients in survivorship in long-term follow-up providing survivorship care plans. And I really think about that when thinking about the roles and responsibilities of an APP, just how vast that really can be. You know, there could be a genetics specialty that the APP chooses where they're providing these APP-led clinics to take care of these special populations of patients. So, just to kind of bring another idea of what the day-to-day could look like, it could be running a survivorship clinic or genetics clinic or palliative care. You know, there are so many, so many things that the APP really can provide in that day-to-day practice. And it's really from diagnosis to survivorship to end-of-life or palliative care. So, we see the patient across that continuum. Dr. Stephanie Williams: Thank you. And Marty, how about you? Marty Clarke: Well, I have for the last several years been working in the office seeing patients, and what I would explain to patients is the oncologist's job really is to decide what your treatment plan is going to be. My job is to get you through that treatment plan successfully and with the greatest amount of comfort. And so, I would see patients, you know, sort of on, sometimes weekly or every other week or every few weeks basis, assess them for where they are, whether, you know, review their labs, make sure that they're fit to continue with treatment, order and evaluate their restaging imaging studies so that we have a good sense of whether or not what we're doing is working as well as we want it to. If it's not, the patient goes back and sees the oncologist for adjustments to the treatment plan. And that's really sort of the just what my office day was like. I did, still do bone marrow biopsies and punch biopsies pretty regularly. The last couple of months, I've been out of the office and working in the hospital sort of as the hospitalist for the group. So, I'm doing consults in the hospital and follow-up while folks are in the hospital. At the time of discharge, I get them, if they're going to have follow- up within our group, then make sure that all that gets set up so that they're not lost in follow-up. I just see my role as being there to help the patient negotiate this very difficult period of their life, to help the physicians that I work with, to be able to use their time most effectively. And to be able to do the things that only they can do. There are some things that I do better than them and that's what I enjoy doing. But it always just goes back to where we started with this earlier. I show up to work every day just trying to help my patients have a little better life. I suspect I'm not unique in that regard. Dr. Stephanie Williams: Thank you! Todd, is there anything else that you would like to add? I know you have more of an administrative lean right now. Todd Pickard: Yeah, absolutely. When I was in full-time clinical practice, a day in my life was really focused on the patient care and how the team could get through the day because normally our schedule in a busy urology oncology practice, we'd have 70 or 80 patients per team that needed to be seen whether they needed a prostate biopsy or a cystoscopy, or they were a pre-op, or post-op, or a new patient or a consult. And so, really, our focus was how we would get through the day, and we would all communicate with each other and support each other. But really, we were focused on each patient getting what they needed and we all were there to serve the patient. And there was a lot of good collaboration. You know, there are times the physician would say, “Hey, I don't know how to get this thing done for this patient. How do we navigate the system?” Or times I'd say, “Hey, you know, this patient is here for surveillance and I've got some concerns about either their labs or this, and this is what I'm thinking. What do you think?” So, it was really that collaboration. I think that's where the strength of APPs and physicians working together is. As an administrator, I spend my time thinking about how policy, and top of license practice and how we credential and make sure that people have good quality care, and I collaborate and partner with all of my other fellow physicians, administrative leaders, and administrative folks. Thank you, Dr. Williams, Leslie, Kathleen, and Marty for sharing your insights today and giving the listeners a glimpse and a better understanding of a typical day in the life and how important it is to understand the differences between APRNs and PAs. They are all an integral part of your oncology practice. Stay tuned for our next episode, and until next time, take care. Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.