Dec 6, 2018
Dr. Kavitha Jennifer Ramchandran, Clinical Associate Professor, Medicine - Oncology at Stanford University. Her clinical focus is in Thoracic oncology and palliative medicine. Dr. Ramchandran served on the Planning Committee for ASCO’s Palliative Care in Oncology Symposium and is here to talk about the event.
Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And
joining me today is Dr. Kavitha Ramchandran, clinical associate
professor of medicine of oncology at Stanford University. Her
clinical focus is in thoracic oncology and palliative medicine. She
served on the planning committee for ASCO's Palliative Care in the
Oncology Symposium and is here to talk about it. Welcome to the
podcast.
Thank you.
Today, we're talking about the Palliative Care in Oncology
Symposium. Palliative care, which is really lessening the burden of
disease and side effects of treatment, is having a moment. It's
becoming more prevalent during earlier phases of treatment, not
just at the end of life. How do you think we got here?
Palliative care is a field in evolution. We've had opportunities
over the last 40 years to see palliative care really evolve both in
Europe and in the United States. As many of you know, palliative
care actually stems from the hospice movement and was started with
the hope that we could provide quality care for patients who are at
the end of life.
The goal was really to enhance a multidisciplinary level of care
for all patients and with a focus not only on their physical needs
but also on their psychological needs, spiritual needs, and social
needs. What we've realized over time, especially in the last 30 to
40 years of medicine, is that we've made a huge leaps in terms of
disease modification. We have new indications for new treatments
every single day, with up to three to four new drugs being approved
for cancer therapeutics every week.
And that excitement has spawned this amazing rush for us to be able
to try to cure and to lessen the impact of illness. However, we're
also realizing that in doing that, we've also created an amazing
epidemic of long-term toxicity and long-term needs that have to do
with patients who are living with illness longer.
And what this means is that palliative care has changed its scope,
where we now are not only caring for patients as they come to the
end of life, but we have to think about what it means to care for
the whole person from the point of diagnosis, including caring for
their symptoms, caring for financial toxicity, looking at the
adverse events of some of these new treatments, paying attention to
the caregiver and family as they negotiate complicated disease
management. It's really about going back to whole person care but
starting at the beginning because people are living longer, and
disease management has become a lot more complicated.
Absolutely. So I'm curious, what information from the Symposium do
you think will yield the most changes going into 2019?
Thanks for asking. I think this was an excellent meeting. I really
hope some of you could have been there in person and are enjoying
the newsfeeds post-meeting. I think one of the things that came out
of this was some of the research on communication.
We are in an era with new treatments that promise amazing things,
including the possibility of cure even for disease that we once
thought was incurable. And with that comes the need to really
balance new communication strategies. There was a group of
researchers that presented data on concepts of hope and optimism
and how we balance that with realistic expectations and
uncertainty.
What we found was that hope unopposed actually can lead to patients
receiving more toxic treatments and that those patients who had
physicians who were able to talk a little bit more about
uncertainty and provide a balanced approach often received
treatment that was more appropriate for them in terms of their
illness and their illness trajectory. Additionally, if you always
offered hope, patients often had lower understanding of their
prognosis and had a lower rate of advance care planning. I think
this really allows us to think about how we educate our clinicians
about balancing hope and uncertainty.
Another piece that came out was in this era, we're really
struggling with the use of opioids. We've had a lot of dialogue
around the opioid crisis in the United States with an increase in
opioid overdoses. And we had a great panel discussion on the great
opioid debate in this meeting, specifically on how we treat
patients who have malignant pain and how we provide them the
medicines that they need to control pain. What stood out for me,
here, was that we really need to think about addiction and
malignant pain as two separate issues. If you have a patient with a
history of addiction, it's important to get help from an addiction
specialist so that you can still provide the medicines and the care
that you need but you also get the advice, as a practitioner, that
you need in order to care for those patients.
Finally, we learned a little bit about guidelines and whether those
guidelines are being followed. Dr. Rolland presented some data on
high emetogenic chemotherapy. He found that even though we've had
guidelines for many years on taking care of patients who are
receiving high emetogenic drugs such as carboplatin and cisplatin,
as practitioners, we're not actually following guidelines. We're
not providing those patients with the right medications to control
nausea and vomiting. And our adherence is often under 30%,
resulting in poor quality of life outcomes for those patients.
And finally, we learned a lot about digital health. We learned
about an AI harness platform from our Boston group that would allow
for us to better understand patients' pain. We also learned about
EMR interventions that would help us to shorten the time to get
patients the right treatment for painful bone metastases and that
we can learn a lot about what patients think by following their
thoughts and voices on local message boards through some of the
work that was done by [? Cindy ?] [? Baggerwall ?] at Santa Clara
Valley.
How should oncology practices use the information from the
Symposium to move the field forward or make process
improvements?
In the area of communication, I think that we have a steep
challenge. We really need to learn to figure out how to communicate
both hope but balance that with uncertainty. And I think those
skills can truly be trained. But that needs to become a focus of
our oncology training programs for all practitioners, whether
they're in nursing, social work, or physicianship, to really think
about how we learn those skills early in our training and practice
them.
Our patients look to us for so much, including not only the latest
cure and the newest science, but they're also looking to us as
guides. They expect us to be able to provide them some honest
guidance on what they should do next. And that needs to be couched
with both data but also our true perspective on what we think might
happen next. And we need to be able to communicate that with
compassion. I think that can be an area that we should be looking
at educational ways to measure our competency there and see whether
that really helps patients make good decisions and help us guide
them to make the decisions.
With regards to guidelines, I think that we've learned that
research helps us to provide new guidelines. For example, with the
high emetogenic chemotherapy, we have learned which drugs work.
We've created the guidelines. Now we need a systems approach. We
need to think about how we can use the EMR to help us to integrate
those guidelines into our e-health solutions so that we make it
easier for our clinicians to do the right thing.
Similarly, when we think about our new research in neuropathy or in
menopause-related symptoms, both of which were also presented, once
we have data and good research and good guidelines, let's create a
systems-based approach that allows us to integrate it into our
technology so that we can make it easier for our clinicians to
practice what we know is correct. And then finally, I think that we
need to keep listening to our patients. We have a whole new host of
ways of learning about what people are thinking, whether it be
social media or discussion boards. And we're going to keep learning
from them.
So let's not forget to use that data and make sure that it helps us
to figure out how we should be talking to patients and where
they're learning their information from. That will help us to make
sure we're on-target with regards to the relevance of the message
that we're communicating.
Is there anything else specific about the Symposium that you would
like to mention?
Yes, I think that there's two really interesting areas that were
highlighted at the Palliative Oncology Symposium that we're just
starting to learn more about. I think we're in the area of early
research and thinking through the appropriate interventions in
order to move these two fields forward.
The first is looking at the adverse events of immunotherapy. This
is a field that we learned a little bit about from the early trials
that looked at comparing immunotherapy to chemotherapy. And most of
those trials indicated that immunotherapy was relatively safe and
that most patients tolerated it without too many side effects.
But our palliative care colleagues were able to highlight the fact
that actually, in the real world, we're seeing higher rates of
toxicity compared to what was shown in the studies. I think that
we're going to have to keep following this cohort of patients that
are receiving immunotherapy over real-time. And we're going to have
to decide, what are the true rates of these adverse events?
There will also be a new field on really learning how to understand
which patients are at highest risk. I think that, in a similar way
that we understand perhaps which biomarkers predict for how
patients respond to certain treatments, we'll also have to start to
think about what biomarkers might predict which patients receive
toxicity from these treatments so that maybe we can either counsel
those patients better or plan for those toxicity. And I also think
it's going to be important for us, as oncologists, to learn how to
manage these toxicities long term, whether it be utilizing steroids
or managing endocrine problems or hepatitides or pneumonitis. These
are all areas that we're all learning a little bit more about as
these drugs become more widely used.
The second area that I think is really important but in a very
different vein is financial toxicity. There was a active and new
group of researchers that presented their work, including Yousuf
Zafar and his team, as well as [? Ian ?] Oliver. And they asked us
to ask patients and families a very simple question. Are you able
to afford your care?
As physicians, we often divorce ourselves from the financial impact
of our treatments on patients and families. Unfortunately, it's no
longer ethical for us to do so. These drugs are coming at great
expense even though they also have great promise. And many times,
patients and families are put in a very difficult situation between
choosing something that could help them to extend their life versus
not maybe having enough money in order to afford their basic living
needs, such as housing or food.
And, as physicians, we need to at least open that door to ask that
question so that we can get them the right support that they need
if finances are becoming difficult. I think that we're going to see
a lot more work on this topic. And I think that we're going to be
changing the way that we practice medicine so that we at least
start to inquire and start to create systems that allow for
patients to get the care that they need but also to be able to live
their life in a way that allows them to get their other needs met,
both for themselves and their caregivers.
Again, today, my guest has been Doctor Kavitha Ramchandran. Thank
you so much for being on our podcast today. And to our listeners,
thank you for tuning into the ASCO Daily News podcast. If you're
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