Oncology Advanced Practice Providers Chemotherapeutic Prescribing Practices
Authors: Christensen Bruce E , Bazany Corinne , Wittenberg Theresa , DeTroye Alisha T , Reinhart Jennifer , Barnaby Keara , Diaz Duque Adolfo Enrique 
Published: November 2021

Abstract
Background:
Physician Assistants (PA) and Nurse Practitioners (NP), referred to as Advanced Practice Providers (APPs), are an integral part of cancer care today in community oncology (ONC) and academic institutions across the country. It has been shown, a team approach using APPs can extend the ONC workforce (PMID: 25009939). The need for ONC services will increase with the rise in cancer incidence and prevalence. As the rise continues, studies have shown ONC services will dramatically increase due to the predicted shortages of oncologists. Increasing the use of APPs is a viable solution to this shortage (PMID: 21037868). PAs and NPs have validated their value by safely prescribing chemotherapy (CT) as they provide cancer care. This value has been key for both patient and physician colleagues. The Association of Physician Assistants in Oncology (APAO) pursued research to better understand CT prescribing practices of ONC PAs. The focus was on whether or not PAs were allowed to prescribe CT drugs in their day to day practice.
Methods:
A survey was used to collect data. The survey focused on APPs scope of practice to include prescribing CT independently (IND) or were there restrictions by the state or organizations they are employed by. For those allowed to prescribe CT, further questions regarding training programs and time periods to demonstrate competency were asked. The survey also viewed physician and employer attitudes towards APPs prescribing CT. The survey was sent in January 2021 to 1307 APAO members via email with a 30-day collection period. Eleven percent were returned (N=149).
Results:
Respondents (R) were PAs, 95%, NPs, 3% and other 1%. The majority of R worked in Hematology/Medical ONC, 87%, with fewer in Surgical ONC 6%, Radiation ONC 1%, other 6%. R came from 34 states with the largest number representing Texas, 13%, New York 12%, Pennsylvania, 8%, North Carolina,7%, Massachusetts 6% and Florida 5%. Most of the R had been in ONC for 1-8 years (y) (59%), followed by 9-16 y (21%), 17-24 y (16%), and 25+ y (3%). The survey was divided into two arms, those who could IND sign CT orders and those who could not IND sign CT orders. The survey demonstrated 44% of the R were able to IND sign CT orders and 56 % of the R could not. With regard to work setting, 60% of R in this arm worked in academic ONC centers and 35% worked in community ONC centers. Also in this arm, 23% were only allowed to sign existing CT plans that did not require modification and 77% were not. The majority of R could sign existing CT orders (89%) and fewer could initiate and sign new CT orders (35%). Most R were able to prescribe intravenous and oral medication (98%), while fewer could prescribe intrathecal 34%) and clinical trial medications (49%).
Of the R in the second arm, 74% worked at academic ONC centers and 19% worked at community ONC practices. When asked if their state medical board prohibited prescribing CT, the majority (77%) reported this was not the case, then if their institution/facilities prohibited prescribing CT, the majority (69%) reported this was true. To explore physician/employer attitudes, a question was posed to ask the APP if their physicians believe that limiting CT to physicians is a safety measure. Responses were mixed, 36% reporting this is true, 33% reporting this was false and 31% as unsure. Next, the APPs were asked if their physicians believed experienced APPs should be allowed to prescribe CT. Again, responses were mixed, 44% agreeing, while 11% disagreeing. Finally, 44% were unsure. When asked if their employer believed limiting CT to physicians is an important safety measure, 47% of the R reported this is true, 19% R reported this is false and 34% were unsure. When asked if their employer believed experienced APPs should be allowed to prescribe CT, 30% of the R reported this is true, 20% R report this is false and 49% were unsure.
Conclusion:
CT prescribing privileges, are not universal for APPs and the reason for inconsistencies in prescribing CT is not clear. This survey provided insight to the wide range of prescribing practices throughout the US based on ONC settings, geographic regions, and experience of the APP. As APPs are valued team members in extending the ONC workforce, and prescribing CT is a common practice in cancer care which APPs participate in. This would seem worthy of further research to understand the reasons why such discrepancies exist.

Disclosures
Diaz Duque: Morphosys: Speakers Bureau; Hutchinson Pharmaceuticals: Research Funding; Incyte: Consultancy; Astra Zeneca: Research Funding; Epizyme: Consultancy; ADCT: Consultancy.