Philippa Cheetham, M.D.: Do you find that most patients are with a caregiver or guest when they come to get their diagnosis? Do you usually recommend that they come with somebody to that appointment?
Edward Kim, M.D., FACP: Yes. It’s really important again to have that champion who is your family member or your friend who can be that other set of ears, that other set of eyes, that other hand writing down the notes. Because you will forget things. It is a very stressful situation, and I think having that kind of support adds to someone’s own overall outcome in a positive way. Philippa Cheetham, M.D.: We always have clear ideas about the information that we want to deliver. You’ve touched on this already, that we want to deliver information about the biopsy, about the treatment options, about the protocol, potentially about clinical trials. But often, the issue that’s troubling the patient may not just be the medical issues. They’re thinking about can I work if I’m having treatment? What does this mean for my family? What does this mean for my general wellbeing? We have to remember that patients have questions that we may not have thought to address, yes?
Edward Kim, M.D., FACP: I can look at you confidently and tell you this is what I tell every patient, is there are certain things we cannot control. But there are a couple of things we can. And I tell them this is what you focus on, 1) eat. If you never heard a doctor say you can eat whatever you want, I tell them you can eat whatever you want now. I’m not a cardiologist, so if we get you to your heart disease and your heart attack then we succeeded, but I don’t want any weight loss. And I will make patients obsessive about their weight because I definitely need them to get those calories in and be prepared.
The second is activity. I don’t want them at home sitting by themselves. I don’t want their caregiver or their children to go get them lemonade. They get up, they go to the kitchen and get it themselves. Go out and walk around. They feel like they have to seclude themselves sometimes because they might catch something from other folks because their immune system is being taxed by these drugs. No, it’s OK to go out, go to the mall, go take a walk, do what normal people do, and that’s what we want our patients to do. There will be some times where there’s added risk, but I want them to live as normal a life as possible with the occasional inconveniences of infusion or side effects. But weight gain and activity is what I stress to all of them.
Philippa Cheetham, M.D.: Now, you’ve mentioned weight loss, and many of us would not connect lung cancer with weight loss. We know that patients who have colon cancer or stomach cancer, you might expect there to be correlation. What’s the significance of weight loss for patients with lung cancer?
Edward Kim, M.D., FACP: I tell people, when you lose weight unexplainably, that’s a really bad sign. Life is just not that good. There are many of us who battle weight on a constant basis, and that’s why some companies make billions of dollars trying to sell you supplements or dietary aspects to do it. When you lose weight unexplainably, that’s not a good sign and that should prompt an evaluation. We see it very commonly with patients with lung cancer diagnosed who lose weight over time, and they also lose their appetite. I’ll ask them to see their driver’s license photo to get a clearer idea. Philippa Cheetham, M.D.: That’s a good idea.
Edward Kim, M.D., FACP: To see what their face looked like when they took a picture back then to when they look now. I’ll turn to the family members and say they’re not eating as much as they used to. “Yes, they used to get second helpings all the time and now they barely finish half a plate.” And these are the things you start subtly picking up over time, and these are not good signs. Philippa Cheetham, M.D.: We know that weight loss for so many cancers means advanced disease. Is that true for lung cancer? Does it mean that if you’ve been losing a lot of weight, by definition it’s already spread beyond the lung, or not necessarily?
Edward Kim, M.D., FACP: Not in all cases, but just as you say, it’s not a good situation. And if you see people losing weight like that, it means the cancer is doing some work inside. Philippa Cheetham, M.D.: We know that patients are going to be offered chemotherapy and radiation therapy. Is it possible to catch up with that weight loss? That cancer weight loss tends to burn through calories quicker than anything else. Can you catch up by eating more calories, or is it just a question of getting on with the treatments, get the disease under control?
Edward Kim, M.D., FACP: I have numerous examples of patients who came back and bragged about their weight, and it wasn’t just fluid retention or anything like that. I had one gentleman in Houston where I told him, I can’t treat you. I told him that, unless you demonstrate to me that you can put weight on because you are losing weight at such a rapid rate, I don’t think the therapy will benefit you. And he said, “please, please, I’ll prove it to you.” I brought him back one week later and he totally faked me out, too. When I came in the room, he lay on the bed in there and he looked all sickly and everything. And I said, how’s it going. He’s like, “oh, you know,” and then he hopped out of it and he said, “I gained 5 pounds from last week.” And I said, wow, you’ve really committed yourself to this, and we started treating him. And so it is possible to reverse it. I think people have to make it more purposeful. Philippa Cheetham, M.D.: Your hesitation to treat him prior to putting on a few extra pounds, is that because you know that the treatment itself, the chemotherapy, is going to knock them back further, or is it more … that they’re just not going to respond as well if they’re immunocompromised or malnourished?
Edward Kim, M.D., FACP: The malnourishment is the tough part. Your body doesn’t handle it well, and if you’re in a state of losing weight, that means you’re not putting calories in. Now we’re going to add an additional stressor of chemotherapy, and they may not be able to handle it.