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Fertility Preservation in Hem-Onc with Ashley Flynn
Discussion with Ashley Flynn about her role in Hem-Onc as a PNP.
Featured Speaker:
In addition to patient care, she also serves as a core group nurse for the Children’s Oncology Group focusing on clinic trials for pediatric liver tumors. Furthermore, she is a provider on the CMH Fertility Preservation Team. In this role, she meets with the families of children, both males and females, who will be receiving radiation or gonadotoxic therapies with the goal to ensure they have the opportunity to have biologic in the future.
When she is not at Children’s Mercy, she enjoys spending time with her husband, Shawn, and their two boys, Sammy (4) and Luke (1). She also enjoys staying active through CrossFit and spending time in the kitchen trying new recipes.
Ashely Flynn, APRN, FNP-C
Ashley Flynn began her career as nurse eleven years ago here at Children’s Mercy in the Pediatric ICU after completing her BSN from the University of Nebraska Medical Center. She spent six years in the PICU as a bedside nurse before graduating with her MSN from the University of Kansas. While working in the PICU, she developed a passion of oncology patients and knew she wanted to be a part of the hematology-oncology-BMT division at CMH. She began working in the Hem-Onc outpatient clinic five years ago as a nurse practitioner.In addition to patient care, she also serves as a core group nurse for the Children’s Oncology Group focusing on clinic trials for pediatric liver tumors. Furthermore, she is a provider on the CMH Fertility Preservation Team. In this role, she meets with the families of children, both males and females, who will be receiving radiation or gonadotoxic therapies with the goal to ensure they have the opportunity to have biologic in the future.
When she is not at Children’s Mercy, she enjoys spending time with her husband, Shawn, and their two boys, Sammy (4) and Luke (1). She also enjoys staying active through CrossFit and spending time in the kitchen trying new recipes.
Transcription:
Fertility Preservation in Hem-Onc with Ashley Flynn
Tricia Williams (Host 1): Welcome to the Advanced Practice Perspectives. I'm Tricia Williams.
Tobie O'Brien (Host 2): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. We will be highlighting our amazing APP's here at Children's Mercy and do some education along the way.
Tricia Williams (Host 1): We are so glad that you're joining us today. It's time to sit back, tune in and let's get started.
Tobie O'Brien (Host 2): Today, we are so excited to introduce to you guys, Ashley Flynn. She is a Hematology Oncology Outpatient Nurse Practitioner. Ashley, thank you so much for joining us today.
Ashley Flynn, APRN, FNP-C (Guest): Thank you guys for having me.
Host 1: Ashley, we're so excited to have you today. As many of you may know, March is Colorectal Cancer Awareness Month and I know Ashley that you have a very personal journey that kind of led you to where you are today. So, I'm ready to talk to you and have our listeners learn more about you.
Ashley: Thank you. So, my story starts way back in college. I attended the University of Nebraska at Lincoln for my Bachelor of Science in Nursing. And my life was great. I was a college student, had great friends. I was doing well in school. And then my junior year of college, I started noticing that I was actually having some rectal bleeding and I didn't think much of it, blew it off for a while.
And after this was occurring for a couple of months. I decided I should go see a doctor about it. And you know, I went to see multiple doctors over a few months. And I was always diagnosed with hemorrhoids or colitis, fissures. All of the diagnoses were relatively minor. So, I again, didn't think much of it continued to go through school, ended up graduating. Accepted a job at Children's Mercy in the Pediatric ICU.
But I was still having this bleeding on again and off again. So, finally I set up an appointment with a primary care provider here in Kansas City, and she said, you know what? This is not normal. You need to get a colonoscopy. And at the time I was 24 years old. And when you talk about a 24 year old getting a colonoscopy, I thought my life was over. I ended up getting the colonoscopy and a large tumor was found. And I was essentially diagnosed with stage three rectal cancer at the age of 24. I was lucky enough to have providers that were thinking about my future and talked to me about preserving my fertility.
So, I actually had my ovaries removed from my fallopian tubes and uterus, and moved up into my oblique muscles. They actually attached them to my oblique muscles so that they would be out of the way of radiation. And then I started chemotherapy. I did six weeks of chemotherapy where I would carry around a little backpack. At the same time, I was also doing radiation. Once I had completed both of those treatments, it was time for surgery to remove the tumor and they were able to completely remove it. However, I did have an ostomy, an ileostomy placed at that time. And then I still had an additional six more months of chemotherapy to do.
So, you know, at the age of 24, I was thrown into this whirlwind of doctor's appointments and making these decisions that I don't believe a 24 year old should ever have to make. But I consider myself one of the lucky ones, you know, I tolerated treatment pretty well. I ended up finishing treatment. So, I started in October of 2011, was able to go back to work in the PICU. While I was going through treatment, I also had the brilliant idea to start graduate school. So, I ended up finishing graduate school in 2015 and that's when I accepted my job in the Outpatient Clinic with Hem-Onc here at Children's Mercy. And I do feel like my oncology experience has helped me and led me to the job that I have today.
Host 2: It absolutely sounds like it. Having to go through something like that at, you said, no 24 year old should have to make those decisions. But yet it sort of helped you on your track to be where you are today and to choose the path of Oncology as a Nurse Practitioner. Thank you for sharing your story, Ashley and how you decided to become an Oncology Nurse Practitioner. Did you already know that you wanted to be a Nurse Practitioner as you were working as a PICU nurse, or did the idea kind of happen while you were getting treatment?
Ashley: So, I always knew that I wanted to go back to school even before I was diagnosed. But when I was working in the PICU, some of the sickest kids that are in the PICU are those oncology or BMT patients. And I really enjoyed taking care of them. I enjoyed getting to know their families. And then with my personal story, I felt like I could in a way, relate to them and had just deeper empathy for what they're going through. So, I knew that when I graduated from my graduate program, that oncology is where I needed to be.
Host 2: Tell us about the group that works in Hematology Oncology. I did a little research and I think I found there are about 26 of you, but that's a really big group. So, can you tell us how it's divided out?
Ashley: Yeah. We have obviously hematology, oncology and bone marrow transplant. So, when we look at oncology, we have Outpatient Nurse Practitioners that are seeing kids in the clinic. We have Inpatient Nurse Practitioners and those Inpatient Nurse Practitioners are on the Chemo Service. So, simply seeing kids that are in the hospital receiving chemotherapy. And we also have a couple of Nurse Practitioners on the Residents Service. So, those Nurse Practitioners are seeing hem- onc new diagnoses and also sometimes children that are receiving chemotherapy as well. On the hematology side, we have Nurse Practitioners that focus directly on COAG specifically inpatient COAG, as well as nurse practitioners that are on our hemophilia team and also sickle cell nurse practitioners. And then we do have nurse practitioners that focus on just general hematology as well. And then on the bone marrow transplant side, you have outpatient nurse practitioners and inpatient nurse practitioners. So, yes, there are a lot of us, but we are divided pretty specifically into certain roles.
Host 1: Very specific. It sounds but it does take a very special human to work in the field of oncology like you do. And I love how you took a profound life event for you and turned it into a passion. Will, you kind of share with us your specific role in what you do in the oncology department?
Ashley: Of course. So, in the outpatient oncology world, I am specifically seeing kids in the clinic. So, I have - The oncology system at Children's Mercy is set up into teams. So, I work with an Attending Physician as well as a Social Worker and we are one team and we see a group of patients that are specifically ours. So, when our patients are diagnosed, they come to the clinic and meet with us. And I'm the one that would be writing their chemotherapy orders. I see them in clinic to admit them to the hospital for chemotherapy. There are some children that can actually get their chemotherapy outpatient. I would be seeing those patients as well.
We also know that kids that are receiving chemo, they can get pretty sick. So, whenever a kid spikes a fever or has excessive vomiting at home and just doesn't feel well, they're coming into the clinic and I can see them as well. We essentially become their primary care providers once they are diagnosed with an oncology diagnosis.
Another interesting part of my job is I have joined the Fertility Preservation Team at Children's Mercy. When I was first diagnosed, the farthest thing that was from my mind was my future children. But luckily I had providers on my team that were thinking about my future and when I was just wanting to get the growing tumor out of my body, they were thinking about my life five, 10, 15 years down the road. So, being able to join the Fertility Preservation Team here at Children's Mercy, I'm hoping to be able to do the same for my patients.
Host 1: Yeah, I want to kind of expand on this a little bit more, because one, I want to know if this is a new concept, like fertility preservation on a two year old that gets diagnosed with leukemia. Like as a parent, I would not be thinking about that. I would be thinking about life-saving measures. Let's get rid of the leukemia. Let's do this. So, how did this all come to fruition? How new is this concept? How received? So many questions.
Ashley: Right. So, what's really great about pediatric oncology is the survival rate keeps going up. So, you know, currently pediatric cancer survival rate is exceeding 80%. So, that means that these kids are becoming cancer-free and living wonderful lives and growing up to be adults. However, there's long-term side effects of their treatments. One of them being infertility. Just even a few years ago, we never even had options to offer to prepubertal patients. So, if a female already had gone through puberty, you could have you know, harvested their eggs, freeze them to be used for future children.
The problem with that is that it can take up to two weeks to stimulate the ovaries and grow the eggs. That's two weeks that you're waiting to start treatment for their cancer. A lot of families, when they find out that their child is diagnosed with cancer, they're not going to wait two weeks to start the treatment.
And as far as males go, pubertal males, they could do sperm collection. And that has been available for many years. What's exciting though, is we now have opportunities for those prepubertal children. So, here at Children's Mercy, we can offer fertility preservation for children as young as six months, that's for males and females.
So, say a little baby girl, what we could offer the family, depending on the risk of infertility with the chemotherapy that she will be receiving, we can offer them what's called ovarian tissue cryopreservation. This is where they actually go in and remove one of the ovaries from the child and freeze it. So, up until about a year and a half ago, this was considered experimental. However, now it's standard of care. So, what we do is take out that ovary, freeze it, and then when the child is grown up and ready to have children, if she's found that she cannot have children naturally, she can use that ovary by actually attaching it to the ovary that is still in her body to try to have a child naturally, which in a way blows my mind. Then another option that is currently being worked on is seeing if there's a way that we can stimulate the ovary that's frozen. Stimulate that in the lab to make it grow follicles, which are essentially eggs. And then those eggs could be used for in vitro fertilization in the future.
Host 2: Incredible.
Host 1: Yeah, totally incredible.
Ashley: Totally incredible. And then for males we have testicular tissue cryopreservation where we actually don't need to remove the entire testicle. They just actually take a biopsy of the testicle. The one thing with this is still in the experimental phase of studies. But it still offers the parents something to preserve their child's fertility, because we don't know what this research is going to show in five, 10, 15 years when they're ready to use the testicular tissue. So, essentially we remove a biopsy of the testicular tissue, freeze it. And then they are working in the lab to see if they can extract sperm that can be used to create a baby in their future as well.
Host 1: So, how do these conversations get started with parents? Because I can only imagine, your child just gets diagnosed with cancer and you have to have those conversations about chemotherapy, radiation, and then how do you jump in and say, let's talk about fertility preservation. Like I'm thinking, my mom side of me is taking over and it's like, I wouldn't want to have those conversations, but they are so important to have. So, how do you start that, do that, accomplish that?
Ashley: So, when their primary oncologist is discussing their treatment plan, whether it be chemo, surgery, radiation or all of the above even. They do discuss the risk of those treatments and long-term side effects. One of those being infertility. So, when they start that conversation, they can then say, however, we have a fertility preservation team here at Children's Mercy that can come discuss your daughter’s risk of infertility in the future. So, then what we do as the fertility preservation team, we look at their treatment plan, see what chemotherapies or what radiation they will be receiving. And determine what their risk is for infertility. There are some patients that have a very low risk of infertility with the treatment that they will be receiving.
And we actually sometimes say, you know, we don't recommend that they go through an ovarian tissue freezing procedure. Because we feel like the risk of the surgery and removing a whole ovary is higher than the chemotherapy that they will be receiving. So, the oncologists that meet with the parents first, prepare the parents that we will be coming to speak with them. And, a lot of the parents aren't thinking about their grandchildren. essentially what they are doing is they're making a decision for their child, male or female that could impact the rest of their life. If they wouldn't do say ovarian or testicular tissue freezing, there's a chance that their child may not be able to have biological children in the future. And that is a lot to take on as a parent.
However, I find that in a way, our options that we're giving parents is also giving them hope. As a parent, yes, you want to treat your child's cancer right now, but you also want to make sure that they're going to be there in 10, 15, 20 years and leading a normal, healthy life. And when we talk to them about their future grandchildren potentially, that gives them hope that their child is going to be okay. It's very heavy though.
Host 1: It is heavy and I have goosebumps just processing it all. Who is on the team? You say we, the team, tell us who and what that team is.
Ashley: So, our team consists of an Oncologist. Also, there are three Oncology Nurse Practitioners, and then we do partner with a Gynecology Nurse Practitioner, as well. So, we are - us five will be the ones who do a lot of the consults. And then we do have Surgeons. So, Surgeons from Urology and also Gynecology. And we also partner with KU, too. They actually do all of the freezing for us, whether it be testicular, ovarian tissue, or even sperm freezing.
Host 2: Ashley, are there success stories of being reimplanted or such that you have heard of or seen firsthand? I know that you are I think I'm, you mentioned five years into this so, are there any stories that you guys share with your families?
Ashley: So, at Children's Mercy, we - since the ovarian tissue process is so new, we don't have any success stories from that yet. However, I have no doubt in my mind that we will. But there are success stories. And it's why, you know, ovarian tissue preservation has become standard of care because babies have been born and babies have been healthy when they're born from ovaries that have been removed from patients prior to chemotherapy, reimplanted once they're ready to have children and born healthy. So, yes, there are success stories.
Host 2: Oh, that's awesome. Well, you, yourself had your ovaries, you said they moved them up. So, was that new at the time?
Ashley: It was. So, actually I was the first case that they ever did at KU where they moved my ovaries to my oblique muscles. And actually they ended up not moving them back down so that I could have children naturally. I do have to go through in vitro fertilization to have kids. And what they do is they stimulated my ovaries to produce eggs. And then partnered with Interventional Radiology at KU to retrieve my eggs that are in my ovaries, up by my ribs, and then took those eggs, combined them with my husband's sperm to create embryos. And I have a little four year old boy, Sam from in vitro fertilization. I have a 19 month old Luke from in vitro fertilization and I have one more frozen embryo waiting to join our family, hopefully someday.
Host 2: Yeah. Well, I have a big smile on my face hearing you say awesome.
Host 1: I would call your boys a huge success story.
Ashley: Yes. Very huge success story. And I, count my blessings every day and I'm just so grateful for all that you know, I've been through and grateful to have a wonderful career and colleagues that support me, family and friends that support me. It's just been, it's been great.
Host 1: Yeah.
Host 2: Do you ever share your story and feel like it connects you better with your families or your kids?
Ashley: So, I don't come out and share my story however. Simply, because I don't want to take away from my patients story. However, there are, situations around the community where I've been part of colon cancer awareness campaigns, whether it be a commercial or a billboard and I'll have the parents of my patients come to clinic and say, you know, are you on that billboard? That's along I-35? I'm like, yeah, that's me. And then it starts the conversation of my colorectal cancer journey.
Host 2: Well, I know it would give me hope so.
Host 1: And your debut. 'You're a model.
Ashley: There's a group called the Colon Club that focuses specifically on colorectal cancer awareness under the age of 50. And they have created what was called the Collander and it featured all colon cancer survivors under the age of 50. And it has now progressed into a magazine, but yes, I was a
Host 1: You were like Miss October, right?
Ashley: I was actually March. Colorectal
Host 1: March. Dang it. I got it wrong. And then I saw your gigantic body on a billboard. I did see that and I was like
Ashley: Yep. That’s me. Then there's also commercial for KU that ran during Royals and Chiefs games. So, yeah. So, go out and get your colonoscopies.
Host 1: For sure. I'm in that age that I think it's time. I think it's time, but tell me how much of your time is spent with this fertility preservation versus caring for your patients in oncology, or do they just all blend together?
Ashley: So, most of my time is spent simply seeing my oncology patients in clinic. Whenever a child comes into the hospital though, and is a new diagnosis, every single new diagnosis patient should receive a fertility consult just so we can review their risk of infertility. And you know, we get about 200 - 250 new oncology cases at Children's Mercy every year. So, essentially we are getting more and more fertility consults as people are hearing about the fertility preservation team at Children's Mercy and learning that there are more options for their patients.
Host 1: That number is staggering to me. So grateful that we have Children's Mercy for our children of our community and had these options for them. A great oncology department, fertility preservation. I mean, it has to give parents hope. It has to.
Host 2: And hearing the rate has gone up to 80%. That is very hopeful and encouraging as
Ashley: It is. And you know, that's why research is so important.
Host 1: Absolutely. Is there other specialties within our hospital that give medications that we should be aware of to maybe do a fertility preservation consultation?
Ashley: So, the other thing that I can think about is there are some Rheumatology diagnoses that are treated with a chemotherapy called cyclophosphamide that does affect their fertility. Most of the time, these are lupus patients. So, we do receive consults from the Rheumatology Division as well for fertility preservation.
Host 1: That's amazing work, Ashley. Are you participating in any research and regarding fertility preservation or oncology? I think research is a great thing for nurse practitioners and physician's assistants to be involved in.
Ashley: So, as far as fertility preservation goes, I am not. However, at Children's Mercy, we're part of the Children's Oncology Group. And the Children's Oncology Group in the United States essentially builds all of the protocols that we follow for chemotherapy for our oncology patients. And I do participate in those clinical trials as well as I'm on a core group of nurse practitioners and nurses that focus on actually liver tumors and reviewing those new protocols that are coming out for liver cancer in pediatrics.
Host 1: Nice work.
Host 2: Yes Ashley. Thank you so much for talking with us today. I mean, your role as an oncology nurse practitioner sounds very fulfilling, so busy. How do you balance it also with your two little boys?
Ashley: Just having good time management. I know, especially as a new graduate, a few years back I felt overwhelmed by the amount that I was taking on. However, you become efficient and learn time management and essentially the outpatient oncology world has been great for great work-life balance, making sure that I'm getting home to you know, spend time with my boys as well in the evenings.
Host 1: Work-life balance is extremely important. I think it's a thing that we all need to work on and master and continue to grow. So, thank you for that. But it has really been a true pleasure to talk with you today and to hear your story. I had the true pleasure of knowing you during your journey. So, thank you sharing it with our listeners. I hope everybody finds it inspiring, and I'm sure that they will. But we like to end each episode with kind of the same question for all of our guests, because we like to hear what y'all have to say. So, if you could go back to one year after you became a nurse practitioner in the Hem-Onc Department, and you could give yourself one piece of advice, what would it be?
Ashley: Ask questions. I feel like that first year coming out of school, I was so nervous driving into work every single day. But I found that my colleagues are incredibly supportive and they want you to succeed. So, that first year is your time to just soak everything in. Ask questions. I know it's so cliche to say that there's no dumb questions, but it's better to ask those "dumb questions" in your first year and figure it out, than keep them to yourself and never quite learn what's right. Be vulnerable. Ask those questions and give yourself some grace because the first year it's nerve-wracking and hard, but soon you will become an expert in your field.
Host 2: Excellent advice.
Host 1: Yeah. Excellent advice. It's hard to do but can we use the term novice to expert in the nursing world a lot. So, it's hard to be an expert as a nurse and then go back to being a novice as an advanced practice provider. So, that is excellent advice.
Host 2: Yes. Thank you for sharing your journey with this big group. I know it's a personal journey and we do appreciate you sharing it with us.
Ashley: Well, thank you so much for having me. It was great. And you know, I hope that I give someone a little bit of hope if their child's going through a difficult diagnosis or if they are going through, you know, cancer themselves or even an infertility journey themselves.
Host 1: You are a success story of my friend.
Host 2: Well listeners, thank you also for tuning in and thank you to Ashley. Guys our next episode will feature Dr. Stephanie Stansell. She is a Nurse Practitioner who also has her PhD in Pharmacology and Pharmaceutical sciences, and a whole lot of other things. But we will be talking with her about her role as an Adolescent Medicine Clinician Scientist. I can't wait. So, thank you for tuning in today.
Host 1: If you have a topic that you would like to hear about, or you're interested in being a guest, you can email us at TdO'Brien@cmh.edu or tWilliams@cmh.edu. Once again, thanks so much for listening to the Advanced Practice Perspectives.
Fertility Preservation in Hem-Onc with Ashley Flynn
Tricia Williams (Host 1): Welcome to the Advanced Practice Perspectives. I'm Tricia Williams.
Tobie O'Brien (Host 2): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. We will be highlighting our amazing APP's here at Children's Mercy and do some education along the way.
Tricia Williams (Host 1): We are so glad that you're joining us today. It's time to sit back, tune in and let's get started.
Tobie O'Brien (Host 2): Today, we are so excited to introduce to you guys, Ashley Flynn. She is a Hematology Oncology Outpatient Nurse Practitioner. Ashley, thank you so much for joining us today.
Ashley Flynn, APRN, FNP-C (Guest): Thank you guys for having me.
Host 1: Ashley, we're so excited to have you today. As many of you may know, March is Colorectal Cancer Awareness Month and I know Ashley that you have a very personal journey that kind of led you to where you are today. So, I'm ready to talk to you and have our listeners learn more about you.
Ashley: Thank you. So, my story starts way back in college. I attended the University of Nebraska at Lincoln for my Bachelor of Science in Nursing. And my life was great. I was a college student, had great friends. I was doing well in school. And then my junior year of college, I started noticing that I was actually having some rectal bleeding and I didn't think much of it, blew it off for a while.
And after this was occurring for a couple of months. I decided I should go see a doctor about it. And you know, I went to see multiple doctors over a few months. And I was always diagnosed with hemorrhoids or colitis, fissures. All of the diagnoses were relatively minor. So, I again, didn't think much of it continued to go through school, ended up graduating. Accepted a job at Children's Mercy in the Pediatric ICU.
But I was still having this bleeding on again and off again. So, finally I set up an appointment with a primary care provider here in Kansas City, and she said, you know what? This is not normal. You need to get a colonoscopy. And at the time I was 24 years old. And when you talk about a 24 year old getting a colonoscopy, I thought my life was over. I ended up getting the colonoscopy and a large tumor was found. And I was essentially diagnosed with stage three rectal cancer at the age of 24. I was lucky enough to have providers that were thinking about my future and talked to me about preserving my fertility.
So, I actually had my ovaries removed from my fallopian tubes and uterus, and moved up into my oblique muscles. They actually attached them to my oblique muscles so that they would be out of the way of radiation. And then I started chemotherapy. I did six weeks of chemotherapy where I would carry around a little backpack. At the same time, I was also doing radiation. Once I had completed both of those treatments, it was time for surgery to remove the tumor and they were able to completely remove it. However, I did have an ostomy, an ileostomy placed at that time. And then I still had an additional six more months of chemotherapy to do.
So, you know, at the age of 24, I was thrown into this whirlwind of doctor's appointments and making these decisions that I don't believe a 24 year old should ever have to make. But I consider myself one of the lucky ones, you know, I tolerated treatment pretty well. I ended up finishing treatment. So, I started in October of 2011, was able to go back to work in the PICU. While I was going through treatment, I also had the brilliant idea to start graduate school. So, I ended up finishing graduate school in 2015 and that's when I accepted my job in the Outpatient Clinic with Hem-Onc here at Children's Mercy. And I do feel like my oncology experience has helped me and led me to the job that I have today.
Host 2: It absolutely sounds like it. Having to go through something like that at, you said, no 24 year old should have to make those decisions. But yet it sort of helped you on your track to be where you are today and to choose the path of Oncology as a Nurse Practitioner. Thank you for sharing your story, Ashley and how you decided to become an Oncology Nurse Practitioner. Did you already know that you wanted to be a Nurse Practitioner as you were working as a PICU nurse, or did the idea kind of happen while you were getting treatment?
Ashley: So, I always knew that I wanted to go back to school even before I was diagnosed. But when I was working in the PICU, some of the sickest kids that are in the PICU are those oncology or BMT patients. And I really enjoyed taking care of them. I enjoyed getting to know their families. And then with my personal story, I felt like I could in a way, relate to them and had just deeper empathy for what they're going through. So, I knew that when I graduated from my graduate program, that oncology is where I needed to be.
Host 2: Tell us about the group that works in Hematology Oncology. I did a little research and I think I found there are about 26 of you, but that's a really big group. So, can you tell us how it's divided out?
Ashley: Yeah. We have obviously hematology, oncology and bone marrow transplant. So, when we look at oncology, we have Outpatient Nurse Practitioners that are seeing kids in the clinic. We have Inpatient Nurse Practitioners and those Inpatient Nurse Practitioners are on the Chemo Service. So, simply seeing kids that are in the hospital receiving chemotherapy. And we also have a couple of Nurse Practitioners on the Residents Service. So, those Nurse Practitioners are seeing hem- onc new diagnoses and also sometimes children that are receiving chemotherapy as well. On the hematology side, we have Nurse Practitioners that focus directly on COAG specifically inpatient COAG, as well as nurse practitioners that are on our hemophilia team and also sickle cell nurse practitioners. And then we do have nurse practitioners that focus on just general hematology as well. And then on the bone marrow transplant side, you have outpatient nurse practitioners and inpatient nurse practitioners. So, yes, there are a lot of us, but we are divided pretty specifically into certain roles.
Host 1: Very specific. It sounds but it does take a very special human to work in the field of oncology like you do. And I love how you took a profound life event for you and turned it into a passion. Will, you kind of share with us your specific role in what you do in the oncology department?
Ashley: Of course. So, in the outpatient oncology world, I am specifically seeing kids in the clinic. So, I have - The oncology system at Children's Mercy is set up into teams. So, I work with an Attending Physician as well as a Social Worker and we are one team and we see a group of patients that are specifically ours. So, when our patients are diagnosed, they come to the clinic and meet with us. And I'm the one that would be writing their chemotherapy orders. I see them in clinic to admit them to the hospital for chemotherapy. There are some children that can actually get their chemotherapy outpatient. I would be seeing those patients as well.
We also know that kids that are receiving chemo, they can get pretty sick. So, whenever a kid spikes a fever or has excessive vomiting at home and just doesn't feel well, they're coming into the clinic and I can see them as well. We essentially become their primary care providers once they are diagnosed with an oncology diagnosis.
Another interesting part of my job is I have joined the Fertility Preservation Team at Children's Mercy. When I was first diagnosed, the farthest thing that was from my mind was my future children. But luckily I had providers on my team that were thinking about my future and when I was just wanting to get the growing tumor out of my body, they were thinking about my life five, 10, 15 years down the road. So, being able to join the Fertility Preservation Team here at Children's Mercy, I'm hoping to be able to do the same for my patients.
Host 1: Yeah, I want to kind of expand on this a little bit more, because one, I want to know if this is a new concept, like fertility preservation on a two year old that gets diagnosed with leukemia. Like as a parent, I would not be thinking about that. I would be thinking about life-saving measures. Let's get rid of the leukemia. Let's do this. So, how did this all come to fruition? How new is this concept? How received? So many questions.
Ashley: Right. So, what's really great about pediatric oncology is the survival rate keeps going up. So, you know, currently pediatric cancer survival rate is exceeding 80%. So, that means that these kids are becoming cancer-free and living wonderful lives and growing up to be adults. However, there's long-term side effects of their treatments. One of them being infertility. Just even a few years ago, we never even had options to offer to prepubertal patients. So, if a female already had gone through puberty, you could have you know, harvested their eggs, freeze them to be used for future children.
The problem with that is that it can take up to two weeks to stimulate the ovaries and grow the eggs. That's two weeks that you're waiting to start treatment for their cancer. A lot of families, when they find out that their child is diagnosed with cancer, they're not going to wait two weeks to start the treatment.
And as far as males go, pubertal males, they could do sperm collection. And that has been available for many years. What's exciting though, is we now have opportunities for those prepubertal children. So, here at Children's Mercy, we can offer fertility preservation for children as young as six months, that's for males and females.
So, say a little baby girl, what we could offer the family, depending on the risk of infertility with the chemotherapy that she will be receiving, we can offer them what's called ovarian tissue cryopreservation. This is where they actually go in and remove one of the ovaries from the child and freeze it. So, up until about a year and a half ago, this was considered experimental. However, now it's standard of care. So, what we do is take out that ovary, freeze it, and then when the child is grown up and ready to have children, if she's found that she cannot have children naturally, she can use that ovary by actually attaching it to the ovary that is still in her body to try to have a child naturally, which in a way blows my mind. Then another option that is currently being worked on is seeing if there's a way that we can stimulate the ovary that's frozen. Stimulate that in the lab to make it grow follicles, which are essentially eggs. And then those eggs could be used for in vitro fertilization in the future.
Host 2: Incredible.
Host 1: Yeah, totally incredible.
Ashley: Totally incredible. And then for males we have testicular tissue cryopreservation where we actually don't need to remove the entire testicle. They just actually take a biopsy of the testicle. The one thing with this is still in the experimental phase of studies. But it still offers the parents something to preserve their child's fertility, because we don't know what this research is going to show in five, 10, 15 years when they're ready to use the testicular tissue. So, essentially we remove a biopsy of the testicular tissue, freeze it. And then they are working in the lab to see if they can extract sperm that can be used to create a baby in their future as well.
Host 1: So, how do these conversations get started with parents? Because I can only imagine, your child just gets diagnosed with cancer and you have to have those conversations about chemotherapy, radiation, and then how do you jump in and say, let's talk about fertility preservation. Like I'm thinking, my mom side of me is taking over and it's like, I wouldn't want to have those conversations, but they are so important to have. So, how do you start that, do that, accomplish that?
Ashley: So, when their primary oncologist is discussing their treatment plan, whether it be chemo, surgery, radiation or all of the above even. They do discuss the risk of those treatments and long-term side effects. One of those being infertility. So, when they start that conversation, they can then say, however, we have a fertility preservation team here at Children's Mercy that can come discuss your daughter’s risk of infertility in the future. So, then what we do as the fertility preservation team, we look at their treatment plan, see what chemotherapies or what radiation they will be receiving. And determine what their risk is for infertility. There are some patients that have a very low risk of infertility with the treatment that they will be receiving.
And we actually sometimes say, you know, we don't recommend that they go through an ovarian tissue freezing procedure. Because we feel like the risk of the surgery and removing a whole ovary is higher than the chemotherapy that they will be receiving. So, the oncologists that meet with the parents first, prepare the parents that we will be coming to speak with them. And, a lot of the parents aren't thinking about their grandchildren. essentially what they are doing is they're making a decision for their child, male or female that could impact the rest of their life. If they wouldn't do say ovarian or testicular tissue freezing, there's a chance that their child may not be able to have biological children in the future. And that is a lot to take on as a parent.
However, I find that in a way, our options that we're giving parents is also giving them hope. As a parent, yes, you want to treat your child's cancer right now, but you also want to make sure that they're going to be there in 10, 15, 20 years and leading a normal, healthy life. And when we talk to them about their future grandchildren potentially, that gives them hope that their child is going to be okay. It's very heavy though.
Host 1: It is heavy and I have goosebumps just processing it all. Who is on the team? You say we, the team, tell us who and what that team is.
Ashley: So, our team consists of an Oncologist. Also, there are three Oncology Nurse Practitioners, and then we do partner with a Gynecology Nurse Practitioner, as well. So, we are - us five will be the ones who do a lot of the consults. And then we do have Surgeons. So, Surgeons from Urology and also Gynecology. And we also partner with KU, too. They actually do all of the freezing for us, whether it be testicular, ovarian tissue, or even sperm freezing.
Host 2: Ashley, are there success stories of being reimplanted or such that you have heard of or seen firsthand? I know that you are I think I'm, you mentioned five years into this so, are there any stories that you guys share with your families?
Ashley: So, at Children's Mercy, we - since the ovarian tissue process is so new, we don't have any success stories from that yet. However, I have no doubt in my mind that we will. But there are success stories. And it's why, you know, ovarian tissue preservation has become standard of care because babies have been born and babies have been healthy when they're born from ovaries that have been removed from patients prior to chemotherapy, reimplanted once they're ready to have children and born healthy. So, yes, there are success stories.
Host 2: Oh, that's awesome. Well, you, yourself had your ovaries, you said they moved them up. So, was that new at the time?
Ashley: It was. So, actually I was the first case that they ever did at KU where they moved my ovaries to my oblique muscles. And actually they ended up not moving them back down so that I could have children naturally. I do have to go through in vitro fertilization to have kids. And what they do is they stimulated my ovaries to produce eggs. And then partnered with Interventional Radiology at KU to retrieve my eggs that are in my ovaries, up by my ribs, and then took those eggs, combined them with my husband's sperm to create embryos. And I have a little four year old boy, Sam from in vitro fertilization. I have a 19 month old Luke from in vitro fertilization and I have one more frozen embryo waiting to join our family, hopefully someday.
Host 2: Yeah. Well, I have a big smile on my face hearing you say awesome.
Host 1: I would call your boys a huge success story.
Ashley: Yes. Very huge success story. And I, count my blessings every day and I'm just so grateful for all that you know, I've been through and grateful to have a wonderful career and colleagues that support me, family and friends that support me. It's just been, it's been great.
Host 1: Yeah.
Host 2: Do you ever share your story and feel like it connects you better with your families or your kids?
Ashley: So, I don't come out and share my story however. Simply, because I don't want to take away from my patients story. However, there are, situations around the community where I've been part of colon cancer awareness campaigns, whether it be a commercial or a billboard and I'll have the parents of my patients come to clinic and say, you know, are you on that billboard? That's along I-35? I'm like, yeah, that's me. And then it starts the conversation of my colorectal cancer journey.
Host 2: Well, I know it would give me hope so.
Host 1: And your debut. 'You're a model.
Ashley: There's a group called the Colon Club that focuses specifically on colorectal cancer awareness under the age of 50. And they have created what was called the Collander and it featured all colon cancer survivors under the age of 50. And it has now progressed into a magazine, but yes, I was a
Host 1: You were like Miss October, right?
Ashley: I was actually March. Colorectal
Host 1: March. Dang it. I got it wrong. And then I saw your gigantic body on a billboard. I did see that and I was like
Ashley: Yep. That’s me. Then there's also commercial for KU that ran during Royals and Chiefs games. So, yeah. So, go out and get your colonoscopies.
Host 1: For sure. I'm in that age that I think it's time. I think it's time, but tell me how much of your time is spent with this fertility preservation versus caring for your patients in oncology, or do they just all blend together?
Ashley: So, most of my time is spent simply seeing my oncology patients in clinic. Whenever a child comes into the hospital though, and is a new diagnosis, every single new diagnosis patient should receive a fertility consult just so we can review their risk of infertility. And you know, we get about 200 - 250 new oncology cases at Children's Mercy every year. So, essentially we are getting more and more fertility consults as people are hearing about the fertility preservation team at Children's Mercy and learning that there are more options for their patients.
Host 1: That number is staggering to me. So grateful that we have Children's Mercy for our children of our community and had these options for them. A great oncology department, fertility preservation. I mean, it has to give parents hope. It has to.
Host 2: And hearing the rate has gone up to 80%. That is very hopeful and encouraging as
Ashley: It is. And you know, that's why research is so important.
Host 1: Absolutely. Is there other specialties within our hospital that give medications that we should be aware of to maybe do a fertility preservation consultation?
Ashley: So, the other thing that I can think about is there are some Rheumatology diagnoses that are treated with a chemotherapy called cyclophosphamide that does affect their fertility. Most of the time, these are lupus patients. So, we do receive consults from the Rheumatology Division as well for fertility preservation.
Host 1: That's amazing work, Ashley. Are you participating in any research and regarding fertility preservation or oncology? I think research is a great thing for nurse practitioners and physician's assistants to be involved in.
Ashley: So, as far as fertility preservation goes, I am not. However, at Children's Mercy, we're part of the Children's Oncology Group. And the Children's Oncology Group in the United States essentially builds all of the protocols that we follow for chemotherapy for our oncology patients. And I do participate in those clinical trials as well as I'm on a core group of nurse practitioners and nurses that focus on actually liver tumors and reviewing those new protocols that are coming out for liver cancer in pediatrics.
Host 1: Nice work.
Host 2: Yes Ashley. Thank you so much for talking with us today. I mean, your role as an oncology nurse practitioner sounds very fulfilling, so busy. How do you balance it also with your two little boys?
Ashley: Just having good time management. I know, especially as a new graduate, a few years back I felt overwhelmed by the amount that I was taking on. However, you become efficient and learn time management and essentially the outpatient oncology world has been great for great work-life balance, making sure that I'm getting home to you know, spend time with my boys as well in the evenings.
Host 1: Work-life balance is extremely important. I think it's a thing that we all need to work on and master and continue to grow. So, thank you for that. But it has really been a true pleasure to talk with you today and to hear your story. I had the true pleasure of knowing you during your journey. So, thank you sharing it with our listeners. I hope everybody finds it inspiring, and I'm sure that they will. But we like to end each episode with kind of the same question for all of our guests, because we like to hear what y'all have to say. So, if you could go back to one year after you became a nurse practitioner in the Hem-Onc Department, and you could give yourself one piece of advice, what would it be?
Ashley: Ask questions. I feel like that first year coming out of school, I was so nervous driving into work every single day. But I found that my colleagues are incredibly supportive and they want you to succeed. So, that first year is your time to just soak everything in. Ask questions. I know it's so cliche to say that there's no dumb questions, but it's better to ask those "dumb questions" in your first year and figure it out, than keep them to yourself and never quite learn what's right. Be vulnerable. Ask those questions and give yourself some grace because the first year it's nerve-wracking and hard, but soon you will become an expert in your field.
Host 2: Excellent advice.
Host 1: Yeah. Excellent advice. It's hard to do but can we use the term novice to expert in the nursing world a lot. So, it's hard to be an expert as a nurse and then go back to being a novice as an advanced practice provider. So, that is excellent advice.
Host 2: Yes. Thank you for sharing your journey with this big group. I know it's a personal journey and we do appreciate you sharing it with us.
Ashley: Well, thank you so much for having me. It was great. And you know, I hope that I give someone a little bit of hope if their child's going through a difficult diagnosis or if they are going through, you know, cancer themselves or even an infertility journey themselves.
Host 1: You are a success story of my friend.
Host 2: Well listeners, thank you also for tuning in and thank you to Ashley. Guys our next episode will feature Dr. Stephanie Stansell. She is a Nurse Practitioner who also has her PhD in Pharmacology and Pharmaceutical sciences, and a whole lot of other things. But we will be talking with her about her role as an Adolescent Medicine Clinician Scientist. I can't wait. So, thank you for tuning in today.
Host 1: If you have a topic that you would like to hear about, or you're interested in being a guest, you can email us at TdO'Brien@cmh.edu or tWilliams@cmh.edu. Once again, thanks so much for listening to the Advanced Practice Perspectives.