Navigating Hematologic Malignancies

Best Practices in Patient Navigation – Navigating Hematologic Malignancies

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Patient Navigation

Introduction

Oncology navigators serve as strong advocates for their patients by helping them navigate their treatment plan and the healthcare system.1,2 Navigators also strive to ensure that care is coordinated among all members of the multidisciplinary team. Clinical navigators and nonclinically licensed patient navigators are responsible for the identification and removal of barriers to timely and appropriate cancer treatment. They guide the patient through the cancer care continuum from diagnosis through survivorship and end-of-life care. Navigators also provide individualized assistance to patients and families affected by cancer to improve access to healthcare services.1,2

Defining Oncology Navigation

The core principles of oncology navigation have been codified by the Commission on Cancer and the Academy of Oncology Nurse & Patient Navigators (AONN+), the leading professional organization for navigators.

The Commission on Cancer defines navigation as individualized assistance offered to patients, their families, and caregivers to help overcome barriers to care. These efforts are intended to facilitate timely access to quality medical and psychosocial care through all phases of the cancer care continuum.3

Similarly, AONN+ defines navigation as the process of “helping patients overcome healthcare system barriers and providing them with timely access to quality medical and psychosocial care from before cancer diagnosis through all phases of their cancer experience.”4

To ensure that patients receive the support needed to optimize their experience, oncology navigators must demonstrate broad knowledge in the following domains of care5:

  • Community outreach and prevention
  • Care coordination and transitions
  • Patient advocacy and empowerment
  • Psychosocial support services and assessment
  • Survivorship and end-of-life care
  • Professional roles and responsibilities
  • Organizational management and healthcare economics
  • Quality and performance improvement

Knowledge in these domains helps the navigator provide patient-centric care that addresses the 5 core goals of oncology navigation: coordinating care, providing education, assessing psychosocial needs and offering support, identifying barriers to care, and advocating for patients.5

Although the core concepts of navigation remain the same, different health systems and cancer centers may have different navigation models in place to achieve these goals. As a result, the specific scope and responsibilities of oncology navigators may vary from one institution to another.

Overview of Hematologic Malignancies and Their Treatment

The foundational principles of oncology navigation hold true for all tumor types; however, there are some important distinctions pertaining to the navigation of hematologic malignancies.

Unlike solid tumors that typically form a defined mass, hematologic malignancies are cancers that affect the blood and lymph system. The disease may begin in blood-forming tissue (ie, bone marrow) or in the cells of the immune system.6 Hematology is a broad medical subspecialty that spans both malignant and nonmalignant conditions; the 3 main types of hematologic cancers are lymphoma, leukemia, and multiple myeloma (Table 1).7-9

NavigatorOrientation_table1

Some hematologic malignancies have an indolent phase and may progress slowly, whereas others may be more acute, requiring immediate treatment. The disease course of hematologic cancers is often variable and can change over time.10 For example, patients with chronic myeloid leukemia may have periodic “blast crises” in which controlling the number of white blood cells in the blood or bone marrow is difficult. Patients may experience particularly debilitating symptoms during these periods of acute disease, which sometimes can be life-threatening.10 This unpredictability can pose a challenge for clinical navigators, who try to inform their patients about what to expect during the course of their treatment.

There are a variety of therapeutic options for patients with hematologic malignancies (Table 2).2,11-15 Treatment depends on the stage and aggressiveness of the disease, the patient’s health status, and the goals of treatment.10 The spectrum of options may be broad. In some cases, the care team will engage in watchful waiting; in other cases, treatment will start immediately.10

NavigatorOrientation_table1

In the past few years, several new drugs have been approved for hematologic malignancies.16 With the wide range of options, there is much for navigators to learn, and it can be challenging to keep abreast of the growing number of new drug approvals. For example, 7 novel drugs were approved for hematologic cancers in 2018 alone.17

Many of these emerging therapies are expensive, resulting in financial challenges for patients and their families. On a positive note, treatment advances in the past 2 decades have extended the life expectancy for many patients with hematologic cancers.18 At the same time, these novel approaches have elevated the importance of survivorship support, since many patients are now experiencing extended periods of remission.

Navigators as Part of the Multidisciplinary Care Team

Regardless of the cancer type, oncology navigators are an integral part of the multidisciplinary team. This team can include oncologists, nurse practitioners, physician assistants, pharmacists, social workers, financial navigators, and others (Figure). It is essential that the team keep the patient and family in the forefront of care. Although there are many players on the team, each has a unique role in caring for the patient. The clinical navigator, using oncology-specific clinical knowledge, acts as a liaison between the patient and the healthcare team, providing education and resources to facilitate informed decision-making and timely access to quality health and psychosocial care throughout all phases of the cancer continuum.2 The navigator has a broad view of the patient’s plan of care and their life circumstances, and often makes suggestions to better manage the patient from a holistic perspective.

NavigatorOrientation_table1

Oncology social workers may also serve in a clinical navigation role. In this capacity, they help patients and families manage the emotional, financial, and physical impacts of a cancer diagnosis through the treatment continuum. Their efforts can range from distress and depression screening to family counseling to assisting with transportation issues.2

Nonclinically licensed patient navigators have a basic understanding of cancer, healthcare systems, and how patients access services across the care continuum, and they perform an important role in connecting patients to information, resources, and support.2

Financial navigators have a more specific role: to help patients by reducing stress or hardship related to the cost of treatment. They assist patients with issues surrounding insurance coverage and out-of-pocket expenses, as well as medication coverage and copay assistance.19 They can connect patients with copay foundations and disease-specific organizations that might provide financial help, in addition to financial assistance programs offered by pharmaceutical companies.

The Role of the Hematology Clinical Navigator

Clinical navigators are usually introduced to new patients early in the process, and may play a role in patient intake into the health system/cancer center. Conducting a thorough assessment is important to identify potential barriers that may hinder treatment. Navigators can help guide the patient through the laboratory testing process, which allows oncologists to make a definitive, differential diagnosis of the cancer.1,2 Once a patient is diagnosed, management of the hematologic cancer is individualized and often complex.10

At the outset, navigators must develop a rapport with the patient and any family members involved in his or her care. For the navigation process to be effective, navigators need to build a trusting and supportive environment for the patient. Because patients may not always be forthcoming with information, communication is one of the top skills navigators need, and it is their responsibility to determine how best to communicate with patients to obtain the necessary information. They must often be creative and think “outside the box” to develop methods to educate and communicate with their patients to be sure they understand their disease and the plan of care. Navigators should also be aware of cultural and language barriers, and the patients and caregivers’ educational needs.1,2

Identifying logistic barriers to care is a vital aspect of the initial assessment. Determining and addressing issues such as transportation and lodging can make treatment more accessible. This applies to all patients but even more to those who travel a great distance to be treated, such as from a different state or country.1,2

Depending on the navigation model employed by the organization, clinical navigators may participate in psychosocial distress assessments, and many navigation programs use the National Comprehensive Cancer Network (NCCN) Distress Thermometer as a method for screening patients.1

Financial toxicity is a concern for many patients with cancer. With the explosion of new drugs in the hematologic cancer field, many new therapeutic options are now available. Unfortunately, patient cost-sharing responsibilities continue to rise.20 It is essential to discuss this issue with patients to allow them to share in the decision-making process regarding their care and drug costs. If a financial counselor or social worker is available, they should be involved in assisting and educating patients surrounding the financial costs of treatment.

In addition to their role advocating for and educating the patient, navigators must be adept at sharing information and coordinating care within the multidisciplinary team. It has been shown that effective patient, caregiver, and healthcare provider communication results in better patient outcomes.21 A recently published article compared time from diagnosis to treatment for patients with and without an oncology navigator. Patients who were part of a multidisciplinary cancer care team that included a navigator versus those who were not had a significantly shorter time (15 days vs 43 days, respectively) between diagnosis and start of treatment.22

During intake and periodically throughout the continuum of care, navigators must be cognizant of the patient’s life goals and be sure they align with the proposed or current treatment plan. Good communication and foresight allow the treatment team to anticipate and address barriers before they become unmanageable.

The Complexity of Hematology Navigation

Hematologic malignancies originate in blood, lymph, and bone marrow, rather than forming a solid tumor. Patients are often unaware of any disease until it is found on routine blood work or by the common symptoms that prompt them to see their primary care physician (PCP) for an appointment and diagnostic workup.10

Management of patients with hematologic cancers is often complex, and there are important clinical nuances specific to different types and subtypes, that must be addressed.10 Hematology is a rapidly advancing field, and navigators must keep abreast of new and often complicated treatment modalities, which continue to be developed and approved.16 In smaller cancer centers and clinics, clinical navigators may not have the opportunity to specialize and are therefore responsible for navigating multiple tumor types, including solid tumors. In addition, navigation can encompass multiple sites of care, both within the multidisciplinary team as well as with outside providers or services. Thus, navigators must develop a broad clinical knowledge base and familiarity with the entire healthcare system to serve their patients effectively.

The hematology navigator is responsible for following the patient over time, but many hematologic cancers may be indolent or slow-growing for a long period, then begin to proliferate aggressively.10 Since these types of cancers cannot be “removed” via surgery, some patients have misunderstandings about the disease. They may believe that the disease is everywhere and they will die. It can be very physically and emotionally challenging for patients to live a normal life knowing that their health status could change at any time.

Although deep, durable remissions can be achieved in many of these cancers, few are curable, and some patients, such as those with multiple myeloma, may require active treatment followed by maintenance therapy for extended periods of time.9,23 For this reason, many hematologic malignancies are referred to as “chronic” cancers. The navigator may be involved with these patients for a long period of time and his/her role will be active at different times throughout the care continuum.

Some patients may undergo one or more stem-cell transplants as part of their treatment. These patients may be referred for prehabilitation before the transplant procedure. Clinical navigators often play a role in care coordination during this period, which is important because prehabilitation can help reduce recovery time and facilitate management after discharge.1

Educating and Empowering Patients

One of the primary roles of the clinical navigator is to provide education at the patient’s level of understanding. Educational handouts must be culturally sensitive and written at the proper reading level and in the patient’s primary language. Interpreter services must be available either in person or through a translation line for these patients to educate them, provide shared decision-making, and obtain informed consent. Patients should be connected to supportive care services at the start of their treatment, including integrative therapies such as art therapy, yoga, and reiki.

According to the NCCN, clinical trials are an important treatment option for many patients with cancer,24 and having knowledge of available trials in hematologic diseases is another important role of the clinical navigator. Although clinical trials can be an integral part of care, patients have many misconceptions about them. Having a deep understanding of the clinical trial process and available open trials will go a long way in helping the navigator educate patients about their benefits as well as recruit them for a trial. Nevertheless, it is important for navigators to know the appropriate time to discuss potential enrollment with the patient; often, the clinical navigator will triage the patient to a clinical trial coordinator (typically a nurse) for further details if they express interest in participating.

Navigators need to understand the nuances of each disease, the available treatment options, and the expected duration of therapy so they can educate patients appropriately. Although oncologists and advanced practice providers may conduct the initial teaching, reinforcing the plan of care is part of the navigator’s role, not only at diagnosis but throughout the cancer journey. Navigators must therefore be familiar with the possible side effects and adverse events of each regimen, since these may be an early and frequent point of contact with the patient.

Navigators can empower patients by identifying strategies that will help them take an active role in their self-care, such as exercise and maintaining a healthy diet. Each patient is unique, and through their rapport, navigators can encourage their patients to participate in constructive activities they enjoy.

Many patients also benefit from support groups and community resources, and navigators can help connect them to these resources. Some recommended resources for patients with hematologic cancers include the following:

  • Leukemia & Lymphoma Society (www.lls.org)
  • International Myeloma Foundation (www.myeloma.org/online-resources)
  • Multiple Myeloma Research Foundation (www.themmrf.org/multiple-myeloma/)
  • OncoLink (www.oncolink.org)
  • NCCN Guidelines for Patients (www.nccn.org/patients/guidelines/cancers.aspx)
  • American Cancer Society (www.cancer.org/treatment/finding-and-paying-for-treatment.html)

There are many excellent evidence-based clinical resources for patients if they want to research their condition or treatment options on their own. However, the navigator must assist the patient in finding reliable web-based and community resources for their specific hematologic disease, because many sites do not provide reliable information.

Ensuring Patient Adherence to Prescribed Treatments

Many therapies for hematologic cancers can be taken orally and can be acquired directly through specialty pharmacies, which may be affiliated with the cancer center or sometimes be an external specialty pharmacy provider. Either way, the navigator should understand the role specialty pharmacies play in delivering therapies to patients, who may encounter substantial cost-sharing requirements when accessing these specialty drugs.20 As such, it is important to make patients aware of pharmaceutical companies’ patient assistance programs that may help defray out-of-pocket costs. Many cancer centers employ financial navigators to help patients through the process of accessing copay assistance services.

Once the patient has initiated treatment, clinical navigators play a central role in ensuring that patients remain adherent to their treatment regimen by frequently reviewing the treatment plan and providing calendars and other tools to help them understand their dosing schedule. Some patients require frequent follow-up calls/visits and instructions to ensure adherence. Checking in on patients if they have a patient portal in their electronic medical record is also a means of keeping patients on track.

Survivorship Planning

Clinical navigators play a vital role in the long-term support of patients who are living with hematologic malignancies. In cancer, survivorship refers to the overall health and life goals of a patient posttreatment through the end of life.25

Navigators assist in providing patients with treatment summaries and survivorship care plans. The information provided should include the following1:

  • Late and long-term side effects of treatment
  • Follow-up medical management
  • Follow-up with PCP to manage comorbid chronic conditions
  • Healthy behaviors (diet, exercise, screenings)

The goal of survivorship care is to transition patients from a treatment-oriented focus to one of health and wellness, while addressing the needs related to their cancer diagnosis and treatment.1 By doing so, survivorship care seeks to improve patient outcomes and help cancer survivors transition to their “new normal.” Survivorship care plans relay information to the patient and oncology care team about the cancer, its treatment, and next steps for care, and can also assist in continuity of care between the team and the patient’s PCP. When transitioning to survivorship, a referral to rehabilitation services may also be needed to allow for deconditioning from frequent hospitalizations and treatments. Research indicates that many patients with cancer require rehabilitation during this transition process.26

When it comes to decisions regarding end-of-life care, it is crucial to integrate the patient’s goals, expectations, and preferences into the plan of care and to maintain an ongoing dialogue throughout the treatment course. It is equally important for the navigator to support the patient’s decision around ending treatment. At the start of therapy, discussing palliative care will help eradicate the myths surrounding it, since many patients associate palliative care with hospice. At end of life, part of the navigator’s role is to facilitate and educate patients/caregivers on the transition to hospice.1,2 Clinical navigators can educate the patient about advance directives and help the patient to obtain one if he/she has not already done so.

Real-World Case Studies of Navigator Support

Clinical and nonclinically licensed navigators must have the skills and resources necessary to support their patients during difficult situations. The following real-world case studies illustrate some of the challenges faced by navigators in their respective roles serving patients. Although the scenarios may differ, each case study demonstrates the integral contribution of the navigator in facilitating a team-based, proactive approach to mitigating barriers and improving access to treatment.

Case Study from a Leukemia Clinical Navigator: 50-Year-Old Male Patient with AML

After noticing unusual fatigue and decreased appetite with a corresponding unintentional weight loss, the patient was referred to a hematologist for pancytopenia and abnormal cells on a peripheral blood smear. Bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia (AML). The patient was referred to a tertiary medical center for induction chemotherapy, followed by consolidation chemotherapy and bone marrow transplant. The treatment was successful, and the patient remains in follow-up care.

However, the AML diagnosis created substantial emotional and psychosocial burdens for the patient and his family, who live on a rural island accessible only by ferry. The distance to care created considerable stress on the patient and caregivers, and no emergency services were available within a reasonable proximity. A small business owner, the patient was unable to work during treatment and therefore experienced financial burden because of loss of income and potential loss of health insurance benefits.

The patient was assigned a team of providers, including oncology nurses, a hematologist/oncologist, a clinical navigator, a dietitian, and a social worker, who collectively helped to coordinate his care. Navigator-facilitated collaboration with his PCP ensured that he underwent close surveillance between chemotherapy cycles. However, several barriers remained. Timeliness in posting routine laboratory results caused delays in recognizing abnormal values. Distance to care required that appointments be clustered to help ease the burden of travel. The 6-hour trip to the transplantation center required careful coordination between the primary oncology care team and bone marrow transplant team. In addition, the patient’s pharmacy needs were challenging and required considerable coordination because of geographic isolation. Timely delivery, storage, and handling were all critical considerations. To help alleviate the burden, 90-day fills were prescribed for certain medications.

In this case, an individualized team-based approach coordinated by a clinical navigator ensured timely access to treatment and coordinated care for the patient under challenging logistical circumstances.

Source: Passwater C, Itano J. Care coordination. Clin J Oncol Nurs. 2018;22:549-554. Adapted with permission.

Case Study from an Oncology Financial Navigator: 32-Year-Old Male Patient with NHL

A young, married, male patient with 3 children was diagnosed with non-Hodgkin lymphoma (NHL). The patient and his wife worked full-time, but he was the primary insurance beneficiary for the family.

The patient was referred for a surgical biopsy procedure in September. After confirmation of the preliminary NHL diagnosis, he was treated with chemotherapy from October through December, followed by radiation therapy beginning in December and ending in January of the following calendar year. The patient missed a considerable amount of work time because of scheduled treatment and perhaps more because of side effects. In addition, his wife (who was the primary caregiver) also missed time from work.

The financial navigator (FN) recognized these workplace challenges and applied for intermittent Family and Medical Leave Act coverage when the patient was not feeling well after chemotherapy. The FN also investigated premium assistance options and provided the patient with information about relevant Americans with Disabilities Act provisions that might protect his employment status.

Since the patient’s treatment extended over 2 calendar years, he incurred 2 annual deductibles ($5000 each year) as well as treatment-related out-of-pocket costs. The FN investigated copay assistance options for chemotherapy as well as radiation therapy. After maximizing the patient’s financial assistance during treatment, the FN filed an application for hospital financial assistance for the remaining balances.

Unfortunately, the family’s financial hardships worsened. The patient’s wife lost her job in October, and the patient was unable to work full-time because of persistent nausea associated with chemotherapy. At this juncture, the FN reviewed the family’s income stream and helped the patient apply for Medicaid, food assistance from the Supplemental Nutrition Assistance Program, and copay assistance. In addition, the FN helped identify resources to assist in paying the mortgage and utilities.

In this case, the FN was successful in identifying resources that helped mitigate financial hardships associated with the cost of cancer treatment and loss of income.

Source: C. Lambert, unpublished case report, February 2019.

Case Study from a Myeloma Clinical Navigator: 72-Year-Old Female Patient with Refractory/Relapsed MM

A patient with suspected multiple myeloma (MM) was referred to a tertiary treatment center. Before the initial consultation, the clinical navigator contacted the patient via telephone to conduct a preliminary assessment and uncovered a number of potential barriers to care.

The patient was widowed and lived alone in a boarding house, with little social support. She was underinsured, having discontinued her secondary Medigap coverage after treatment. She used public transportation to get to therapy but only traveled during daylight hours. The navigator contacted the team of financial counselors to let them know that a new patient would likely require financial assistance to help pay for treatment.

After confirmatory testing was completed, the patient received a definitive diagnosis of MM. At that time, she was not familiar with targeted therapies and the potential toxicities associated with their use. The patient also had hypertension, which required a combination of 2 oral medications to maintain blood pressure control.

The clinical navigator referred the patient to financial counselors for discussions about reestablishing secondary insurance and identifying an affordable prescription plan, as well as other copay support resources. In addition, the patient was referred to a social worker to address concerns regarding housing, transportation, and additional supportive care resources such as food banks. The clinical navigator also followed up with the patient frequently to ensure adherence to her oral therapies, which included dexamethasone and antihypertensive drugs.

In addition, the clinical navigator scheduled a separate visit to educate the patient about MM and the treatment plan. Several treatment team members took part in this informational session.

Subsequently, the patient received multiple treatments over an 8-year period, with the last treatment ending 2 years ago. She did not receive a stem-cell transplant. After having relapsed, the patient was prescribed a combination regimen of cyclophosphamide, bortezomib, and dexamethasone, which she had tolerated in the past with minimal toxicities and a good clinical response.

At relapse, the clinical navigator and other treatment team members reassessed the patient’s barriers to care. Collaboration with her team ensured that she was able to receive and continue on treatment. Having followed the patient for several years, the clinical navigator understood the challenges faced by this patient and re­engaged her, postrelapse, to assess her current circumstances.

In this case, the patient was able to complete the bortezomib-based chemotherapy regimen and entered another period of remission without undue financial hardship or logistic barriers.

Source: M. Rummel, unpublished case report, February 2019.

Conclusion

Oncology navigators play a central role in helping patients address issues that can adversely affect treatment outcomes. As with virtually any cancer, patients diagnosed with hematologic malignancies must contend with complex treatment regimens, as well as psychosocial, financial, and logistic barriers that complicate the management of their disease.

Hematology navigation can be a challenging but rewarding experience. Because cancer navigation is not a static profession, there is a great deal to learn, and professional development is an ongoing process. There are numerous educational opportunities for clinical and nonclinically licensed patient navigators, including attending conferences or other continuing education programs. Expert navigators frequently serve as mentors and role models for staff members who are new to the navigation role.

Because navigators are constantly helping others, they also need to take some time for self-care and reflection. To remain effective members of the treatment team, they need to maintain a work-life balance and do things they enjoy when not working. This balance is critical to help navigators avoid “compassion fatigue.”

Being a navigator is a fantastic job. It is both an art and a science. Navigators have a great deal to offer, but most importantly, it is good to know they are making a difference in the lives of their patients.

References

  1. Gentry SS, Sellers JB. Navigation considerations when working with patients. In: Blaseg KD, Daugherty P, Gamblin KA, eds. Oncology Nurse Navigation: Delivering Patient-Centered Care Across the Continuum. Pittsburgh, PA: Oncology Nursing Society; 2014:71-120.
  2. Shockney LD, ed. Team-Based Oncology Care: The Pivotal Role of Oncology Navigation. 1st ed. Cham, Switzerland: Springer International Publishing AG; 2018.
  3. Commission on Cancer. Cancer Program Standards: Ensuring Patient-Centered Care. Chicago, IL: American College of Surgeons; 2016. www.facs.org/~/media/files/quality%20programs/cancer/coc/2016%20coc%20standards%20manual_interactive%20pdf.ashx. Accessed February 6, 2019.
  4. Academy of Oncology Nurse & Patient Navigators (AONN+). Helpful definitions. AONN+ website. www.aonnonline.org/education/helpful-definitions. Accessed February 6, 2019.
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  6. National Cancer Institute (NCI). NCI dictionary of cancer terms: hematologic cancer. NCI website. www.cancer.gov/publications/dictionaries/cancer-terms/def/hematologic-cancer. Accessed January 17, 2019.
  7. Rummel M. Non-Hodgkin lymphoma and Hodgkin lymphoma: the role of the nurse navigator in improving patient outcomes. J Oncol Navig Surviv. 2015; 6(3 suppl):3-10.
  8. American Cancer Society (ACS). What is chronic myeloid leukemia? ACS website. www.cancer.org/cancer/chronic-myeloid-leukemia/about/what-is-cml.html. Last revised June 19, 2018. Accessed February 11, 2019.
  9. Tariman JD, Faiman B, eds. Multiple Myeloma: A Textbook for Nurses. 2nd ed. Pittsburgh, PA: Oncology Nursing Society; 2015.
  10. Olsen M. Overview of hematologic malignancies. In: Olsen M, Zitella LJ, eds. Hematologic Malignancies in Adults. 1st ed. Pittsburgh, PA: Oncology Nursing Society; 2013:1-17.10.
  11. American Society of Clinical Oncology. ASCO answers: understanding chemotherapy. Cancer.net website. www.cancer.net/sites/cancer.net/files/asco_answers_chemotherapy.pdf. Accessed March 5, 2019.
  12. National Cancer Institute (NCI). Biological therapies for cancer. NCI website. www.cancer.gov/about-cancer/treatment/types/immunotherapy/bio-therapies-fact-sheet. Last reviewed April 26, 2018. Accessed March 11, 2019.
  13. American Society of Clinical Oncology. What is a bone marrow transplant (stem cell transplant)? Cancer. net website. www.cancer.net/navigating-cancer-care/how-cancer-treated/bone-marrowstem-cell-transplantation/what-bone-marrow-transplant-stem-cell-transplant. Published August 2018. Accessed March 5, 2019.
  14. American Society of Clinical Oncology. Understanding radiation therapy. Cancer. net website. www.cancer.net/navigating-cancer-care/how-cancer-treated/radiation-therapy/understanding-radiation-therapy. Published May 2018. Accessed March 5, 2019.
  15. Lin K-T, Wang L-H. New dimension of glucocorticoids in cancer treatment. Steroids. 2016;111:84-88.
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  17. US Food and Drug Administration (FDA). 2018 novel drug approvals. FDA website. www.fda.gov/drugs/developmentapprovalprocess/druginnovation/ucm592464.htm. Last updated January 15, 2019. Accessed January 19, 2019.
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  19. National Cancer Institute (NCI). NCI dictionary of cancer terms: financial navigator. NCI website. www.cancer.gov/publications/dictionaries/cancer-terms/def/financial-navigator. Accessed March 5, 2019.
  20. National Cancer Institute (NCI). Financial toxicity and cancer treatment (PDQ®)—health professional version. www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq. Updated January 25, 2019. Accessed March 6, 2019.
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Last modified: April 17, 2019

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