Philippa Cheetham, MD, and Sara F. Martin, MD, discuss the role of a palliative care specialist in managing treatment side effects in advanced lung cancer.
PUBLISHED November 13, 2017
Philippa Cheetham, MD: Welcome back to CURE Connections®. We’re talking about lung cancer, and, in this segment, we’re focusing on some of the exciting advances in the management of advanced lung cancer. We’ve already talked about some of the advances in early lung cancer. Dr. Martin, you are involved in palliative care. We’ve talked a lot about medical advances—the new drugs, the new radiation protocols, the new imaging. But patients often struggle with the side effects of treatment. Where are we now, compared to 10 years ago, in managing the side effect profile of these therapies? Are there improvements in how we manage patients’ side effects of the treatment that we’re giving them?
Sara F. Martin, MD: Yes, to both questions, I would say. Many of the newer agents tend to have less side effects for patients. And I think we’re doing a much better job in managing side effects overall, not only during treatment or preparing patients so that they don’t get side effects, but also once treatment is complete. There’s also more medications available for patients for control of common side effects. There’s really no reason someone should have uncontrolled nausea and vomiting from their cancer or their treatment, at this point.
Philippa Cheetham, MD: We know that these treatment options are available, and we’ve done segments on CURE Connections® that have addressed chemotherapy-induced nausea and vomiting. And as you said, there’s no reason why a patient should suffer from those side effects. But isn’t it important that we ask the right questions to patients to make sure that we check that they’re not having these side effects? How easy is it for patients to get to the doctor if they feel these side effects on a Friday night and the office is closed for the weekend?
Sara F. Martin, MD: As a cancer doctor, you have to be proactive in giving patients medications and doing good medication counseling on how to use those medicines when you have a symptom. It’s not uncommon to meet patients that have a lot of medications at their disposal and don’t know what to use and when. The other thing, and the nice thing about being a palliative care physician that works with oncologists, is that sometimes patients want to put on their best face for their cancer doctors, so they don’t want to report some of their side effects. They’re worried. Everyone wants their doctor to like them and think that they’re doing the right thing in taking the treatment. So, sometimes it’s nice to have a third party removed. You can really just talk about what symptoms are bothering you and maybe get more treatment, from that angle.
Philippa Cheetham, MD: We’ve talked about how to manage side effects when they appear, but I guess a large part of your job is educating the patient, up front, of side effects that they may expect to have. Is that part of the initial consultation? Do you pre-warn patients of what to expect?
Sara F. Martin, MD: It can be. For many specific side effects to treatments, I actually leave that conversation to the cancer doctors, themselves, because they’re the ones prescribing the chemotherapy. They are more knowledgeable of the exact side effects that may be expected. As we talked about earlier, some side effects are universal. Fatigue tends to be universal. Most people will experience some loss of appetite. So we can talk, up front, about general things to expect from treatment with anybody living with a serious illness. If you think about it, when you have a stomach virus, you’re tired and you don’t want to eat a lot. Cancer is that, times a thousand, for a lot of patients.
Philippa Cheetham, MD: You work on a team with nurse practitioners and palliative care nurses that have the time to spend with patients to address these issues, yes?
Sara F. Martin, MD: Correct. I have a whole team of providers that work with me. They are knowledgeable, specifically on symptoms. We’ve already talked about nausea and vomiting, but sometimes it’s getting the right medicine at the right time to ensure that patients don’t have that nausea and, therefore, do not vomit. Sometimes patients just aren’t aware of which medicine to take and when, and it can be fixed with some easy education.
Philippa Cheetham, MD: And the caregiver has a huge role to play in helping report these symptoms and side effects that patients don’t always want to report themselves?
Sara F. Martin, MD: Correct.
Philippa Cheetham, MD: You’re involved with helping people in the community as well as in hospitals, yes?
Sara F. Martin, MD: Correct.
Philippa Cheetham, MD: And with these newer agents, many patients are getting treatment as an outpatient, yes?
Sara F. Martin, MD: Yes.
Philippa Cheetham, MD: If they’re being given medications as an outpatient, do you think that a lot of these side effects are hidden because people are at home as opposed to when we were treating people in the hospital and we were rounding on them and seeing them every day?
Sara F. Martin, MD: I don’t know that they’re necessarily hidden. I think it probably depends on the degree of the side effect and the person. Some people will stay home and not talk about it, and some people will call the minute they get sick to their stomach. It just depends on the patient. But, you have to be ready and available for patients and families, whatever their questions may be. The patient might not want the side effect reported, but the family member might really want to talk about what’s happening and, “How do I deal with this?”
Philippa Cheetham, MD: Right. A lot of the side effects that you’ve mentioned, particularly with these newer treatments, are very nonspecific—the fatigue, the nausea. Do you think that because these symptoms are symptoms that may be related to taking many medications, the treatment, the travel, and the emotional exhaustion, does it make it harder to treat because they’re these nonspecific symptoms?
Sara F. Martin, MD: It certainly can. That’s where it’s nice to have someone like a palliative care specialist who has more time to try and parse out with the patient and family what’s driving the symptom. Maybe you’re nauseated because you got sick with your first chemotherapy and now you’re worried that your next chemotherapy is going to make you as sick? You’re already feeling sick before you even get the drug. That’s real, but that’s anxiety. And so, we need to treat that differently—that type of nausea versus nausea from chemotherapy.
Philippa Cheetham, MD: Sure, and specialists are much more likely to hone in on those issues than somebody who’s not so familiar with them.