Prescribing Chemotherapy as an NP: Factors to Remember

In the United States, there is a growing number of patients with cancer and those who have survived cancer. This, coupled with increased access to health care through the Affordable Care Act and a shortage of oncologists, highlights the importance of and need for advanced practice providers (APPs) in the cancer space.

Who Can Prescribe Chemotherapy?

APPs such as nurse practitioners (NPs) are essential members of the health care team when it comes to educating, monitoring, and (where allowed) diagnosing cancer and prescribing drugs to patients with the disease. Currently, NPs have full practice authority in 24 states, meaning they can evaluate patients, give diagnoses, order and interpret diagnostic tests, and prescribe and manage treatments. Sixteen states, however, require NPs to collaborate with physicians, and 11 states have restricted practice so that NPs must be supervised, delegated, or managed by an outside health discipline.

“When we think about ordering or prescribing oncologic therapies, it’s not 1-size-fits-all. It requires immense critical thinking and many considerations need to be [discussed] throughout the whole process,” said Kim Noonan, DNP, ANP-BC, AOCN, chief nurse practitioner at Dana-Farber Cancer Institute.

Noonan and Suzanne McGettigan, MSN, ANP-BC, AOCN, a nurse practitioner and clinical manager at Penn Medicine, discussed the role of APPs in prescribing oncologic agents in a presentation at the 46th Annual Oncology Nursing Society Congress. State laws, hospital policies, and patient status are the 3 aspects that APPs must consider when prescribing cancer care, Noonan said.

As NP practice authority varies from state to state, differences also exist among institutions. Organizations can regard the act of prescribing chemotherapy as a core competency, meaning the provider has the knowledge, skill, and educational background to complete the task, or as a privilege, meaning practitioners apply for the right to complete such a task. The institution will make a decision based on the person’s credentials and performance.

Ensure Chemotherapy Safety

NPs must consider many patient-safety aspects when prescribing chemotherapy, because cancer therapies are high-risk drugs.

“We know that cancer therapy is very high risk. There has been a lot published about the number of medication errors [and] dosage errors with chemotherapy,” McGettigan said. “It is essential that we are cognizant of all these aspects of patient care as we are filling these orders and prescribing these therapies.”

First the NP must review the pathology, confirm the disease and stage, and talk with the patient to understand their goals of care.

Then they must complete a medical history review, including any patient allergies; complete and document patient education and/or informed consent; and complete a chemotherapy plan. The plan includes the drugs the patient will receive and the dosage, treatment duration, and how the patient will be monitored.

The hard work is not over once the patient has signed the informed consent forms and the NP has prescribed treatment. Now the NP must work with the entire oncology team to implement ongoing patient and family education and monitor for toxicities. When adverse events occur, NPs should take the lead on documenting the toxicity and its grade, and adjusting therapy if needed.

“Oncology NPs are educated, trained, and experienced and can play a very essential part in therapy for patients with cancer,” Noonan said.