NEW YORK – When Melissa Cruz-Tanner started working as a patient navigator at a New Jersey-based community cancer center Aster Cancer Care in 2018, few if any patients were getting comprehensive biomarker testing.
"The testing process and how to order them was very, very antiquated when I first started," said Cruz-Tanner, who is now Astera's manager of patient navigation and molecular processing. A lot of the cancer patients wouldn't get genomic testing, she recalled, because they weren't educated on the need for testing, or because their insurance wouldn't cover it, or because testing just wasn't feasible.
In her nurse navigator role, Cruz-Tanner started stepping in and ordering biomarker tests on behalf of already overworked oncologists, collecting for them the clinical data needed to interpret the results and making sure that the results came back on time. But it quickly became clear that the task was a full-time job, and nurse navigators had their hands full already, serving as patients' main point of contact throughout their treatment. "As you can imagine, once we were making that [biomarker testing] accessible to every single malignant patient that qualified, the volume became way too high for the navigators," she said. "We had to come up with something else that would be more feasible and sustainable in the long run."
Fast forward five years and Cruz-Tanner's team now includes patient navigators and other dedicated support staff who screen incoming patients for biomarker testing eligibility and ensure that test ordering specimen procurement and delivery of test results to providers happen smoothly. They also stay in close contact with testing labs to ensure they're meeting advertised turnaround times and coordinate any prior authorizations required for insurance coverage.
These precision oncology stewards, sometimes called "molecular processors," together with Astera's patient navigators, serve as patients' direct point of contact in coordinating lab appointments, office visits, and follow-ups. Although institutions that are investing in infrastructure to deliver precision oncology increasingly see these new support staff as critical to delivering timely and accurate patient care, these new roles aren't supported widely at healthcare institutions around the country.
Elana Plotkin, the director of provider education programs at the Association of Community Cancer Centers, has been working on an educational campaign to bolster community oncology providers' recognition of precision medicine stewards, ideally leading to more cancer centers investing in their own stewards.
Toward this end, ACCC launched a provider education program a year and a half ago aiming to bolster the case for precision medicine stewards, especially in the community cancer setting. The association recently published a collection of detailed case reports, showing how individual cancer centers navigated the hurdles of establishing a precision medicine stewardship program. Astera's experience was featured among them.
Plotkin recognized some cancer centers might refer to precision medicine stewards by different titles, such as "molecular processors" in the case of Astera, but the fundamental idea is the same. "A precision medicine steward is someone that is the champion within a cancer program when it comes to managing biomarker testing and the entire care coordination process that goes into that biomarker testing," Plotkin said. "It solves a lot of the problems that occur along the timeline of getting the right patient and the right treatment at the right time."
According to Plotkin, precision medicine stewards are uniquely important in the community cancer setting for a handful of reasons. For one, community oncologists are often spread thin. They treat many patients with a variety of cancers at different stages of progression every day. They might not have the chance to stay abreast of the constantly changing testing guidelines and latest biomarker test options. And even at cancer centers with in-house molecular testing, doctors can order tests from different commercial labs with varying test specifications and turnaround times, making it hard to keep track of patient testing.
And when the results come back, Plotkin continued, there can be lag time and issues uploading them into a usable file in the cancer center's electronic health system. "This precision medicine steward can help make sure the results are getting into the right place in the EHR, so they can then schedule patients quickly for the follow-up visits that need to occur, and then get those patients onto therapy as a result of that."
Precision medicine stewardship programs can be uniquely helpful in the community oncology setting, Plotkin added, since patients at these institutions often lack insurance or are underinsured and need help paying out-of-pocket costs associated with biomarker testing. Precision medicine stewards, ideally, work directly with test navigators to tap into financial assistance programs.
According to Cruz-Tanner, many labs are willing to offer free testing, or even genetic counseling services to patients who can't afford it, but these options aren't always advertised. "In the beginning, we didn't even know that the vendors could do so much on our part," she said. Precision medicine stewards like Cruz-Tanner establish relationships with labs, become familiar with their policies, and can help patients reduce financial toxicity by quickly tapping into opportunities to reduce test costs.
"People can lean on the vendors more than they think that they can," Plotkin echoed. "Working in partnership with the vendors is a huge benefit" of establishing a precision medicine stewardship program.
According to Plotkin, precision medicine stewards can come from a variety of backgrounds including nursing or pathology. It's preferred that these individuals have clinical and administrative experience as well as familiarity with biomarker testing labs and patient eligibility guidelines.
Based on the experience at Astera, Cruz-Tanner has observed that certified medical assistants (CMAs) are strong candidates for the role. "It would need to be someone that had sufficient clinical understanding, but that was trained in a manner that they would work hand-in-hand with the navigator if there was any kind of inquiry that [the navigator] wasn't able to approach," she said. "A CMA is the ideal candidate, because they're cost-efficient for the practice, and they also had that clinical background that would allow them to understand the basics needed for the [test] order processing aspect."
But even at Astera, it took a lot of work to create the role of molecular processor and build out a whole precision medicine stewardship team. Cruz-Tanner recounted how establishing the molecular processor position meant itemizing every step involved in the biomarker testing process and presenting leadership with this list of tasks, which at the time did not fall into any other provider or administrator's job description. Astera first agreed to appoint a single medical assistant to the role. Then, six to nine months later, Cruz-Tanner said the amount of overtime pay that single person was getting convinced Astera to hire a second molecular processor.
"We took that information to our leadership and said, we have now grown enough not only in the size of the practice, but in the accessibility for our patients to have testing," she said. Now, Cruz-Tanner manages an entire precision medicine stewardship team that includes nurse navigators and molecular processors.
Although precision medicine stewardship programs are in their infancy, Cruz-Tanner believes that the investments Astera has made has allowed more patients who need biomarker testing to receive it. During the first quarter of 2022, she and her team ordered a total of 200 biomarker tests for patients at Astera. As of the first quarter of this year, that number has more than doubled to 435 orders. Going forward, Cruz-Tanner said it will be necessary to secure enough investment to ensure the program can keep pace with the growing test demands and advancing science.
In Plotkin's view, the challenge is to educate payors, providers, and cancer centers across the country about the important role precision medicine stewards play in expanding access to biomarker testing. Broader recognition, she hopes, will further demonstrate the value and cost benefits of this new role.
"Patient navigation is prevalent, but having someone who's this specific type of champion is really innovative," she said. Community sites facing care coordination challenges have increasingly expressed interest in learning from ACCC about the process of establishing a stewardship program.
ACCC's provider education program, of note, receives financial support from AstraZeneca and Blueprint Medicines, but Plotkin said it's independently shaped by ACCC and its partnered associations, the Academy of Oncology Nurse & Patient Navigators and the American Society for Clinical Pathology. In addition to recently published case studies of institutions that have launched precision medicine stewardship programs, ACCC's education effort includes podcasts, webinars, and tip sheets for interested institutions.
"We're bringing awareness to this role overall, because it is a new way of thinking about things," Plotkin said. "I'm hoping that we see more precision medicine steward job posts popping up across the country, and that it grows as a subset of a profession because … precision medicine biomarker testing is expanding so rapidly. We want to make sure that patients have access to the latest and greatest in approved, guideline-concordant care."