GRACE :: Treatments & Symptom Management

Hospice is HELP: Avoid it at Your Peril

I’m on call for my oncology group this weekend, and I’ve had the situation come up twice in less than 24 hours that a patient is in dire need of home-based symptom management, with plans for hospice just getting initiated in a mad scramble on a Saturday or Sunday.  In both cases, the patient is sick enough and far enough from the hospital that just evacuating them with a 911 call isn’t an effective way to solve the problem.  And so what could otherwise be a legal urgent delivery of pain medications to a hospice patient is a difficult night of toil and unnecessary suffering because there isn’t a mechanism to get medications or support for someone who will be enrolling on hospice tomorrow, after weeks of the patient and/or family resisting an appropriate and well-meaning recommendation to enroll earlier.

It’s a terrible shame that, in the US at least, hospice care is usually initiated at a point when death is just a few days or even hours away.  Too often it’s a race for hospice nurses to get to the patient in time to provide needed comfort and support in the last moments of a person’s life, after the patient and their family and friends have already struggled through the rapid changes and symptoms of dying.  If it isn’t “too little, too late”, it’s close.   But hospice teams can provide critical value and support if referrals are made long enough for the patients and families to develop a good relationship with the folks from hospice.

This seems to stem from a tendency to want to deny, to wish away, any acknowledgement that a person’s disease is terminal (sometimes by doctors, sometimes by families, sometimes by the patient himself or herself), as if avoiding the subject and the needed action will keep it from happening.  But a person will continue to decline, death will unfortunately ensue, and the only consequence of postponing to the point of critical distress and unavoidable recognition of the reality is that everyone experiences far, far more suffering and chaos than they would have otherwise.

It’s understandable that people don’t want to embrace a sad reality when death is becoming close enough to anticipate and plan for. In truth, death is rarely a beautiful experience, but it can often go from being terribly challenging and unpleasant to minimally so when there are people nearby who are equipped and motivated to help, and who have the experience to guide people.  I think it’s a very sad, regrettable mistake to not avail themselves of that help until it’s an absolute crisis.  


Dr. Harman on Depression and Cancer-Related Fatigue

 

 

Here is the last of four podcasts from Dr. Stephanie Harman’s terrific presentation on common cancer-related symptoms.  This one focuses on the common issues of depression and cancer-related fatigue.  Below you’ll find the audio and video versions of her presentation, along with the associated transcript and figures.

 

 

Dr. Harman Depression and Fatigue Audio Podcast

Dr. Harman Depression and Fatigue Figs 

Dr. Harman Depression and Fatigue Transcript 

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Dr. Stephanie Harman on Nausea and Management Options

 

The third installment from Dr. Harman covers nausea and options to manage it.  She discusses both chemotherapy-induced nausea and some other potential causes.  

Here is her talk in both video and audio podcast versions, along with the transcript and figures.

Dr. Harman Nausea Audio Podcast

Dr. Harman Nausea Transcript

Dr. Harman Nausea Figs

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Dr. Harman on Cancer Pain Management

Here’s the second part of Dr. Harman’s webinar on managing common cancer symptoms, in which she discusses the basic tenets of cancer pain management.  

Dr. Harman Pain Management Audio Podcast

Dr. Harman Pain Management Transcript

Dr. Harman Pain Management Figs

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What is Palliative Care?

Here is the first portion of a podcast by Dr. Stephanie Harman, GRACE faculty member and Director of the Palliative Care Program at Stanford University in Palo Alto, CA.   Before embarking on a discussion of several integral symptoms and how best to manage them, Dr. Harman began with a step back and brief discussion of the distinctions between palliative care and hospice/end of life care, as well as the growing attention palliative care is now receiving from many professional societies.  

Dr. Harman What is Palliative Care Audio Podcast

Dr. Harman What is Palliative Care Transcript

Dr. Harman What is Palliative Care Figs

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Book Recommendation: Dr. Lacouture’s Skin Care Guide for People Living with Cancer

In the last few years, oncologists have needed to become far more capable at managing dermatologic issues than we used to be.  Though the rashes so associated with EGFR inhibitors may be the easiest thing that leaps to mind, plenty of other treatments, including many chemotherapy drugs and immunotherapies, have significant effects on skin, hair, nails, eyes, and other mucosal surfaces.  

However, even though more and more cancer patients are struggling with acute and chronic side effects from dermatologic issues, it’s fair to say that very few oncologists have enough knowledge and experience to serve our patients as well as we’d hope to.  That leaves us either struggling on our own or referring patients to dermatologists who often aren’t really familiar with the specific challenges faced by cancer patients from the treatments and/or the underlying disease.  What we really need is the expertise of one of the very few dermatologists who specializes in skin, hair, nail, and eye problems related to cancer and its treatments.

Dr. Mario Lacouture is arguably the leading figure in that regard.  He became recognized as the preeminent expert in this field while at Northwestern University in the Chicago area, then relatively recently was recruited to head a clinic dedicated just to dermatologic issues for patients at Memorial Sloan-Kettering Cancer Center in New York City.  Dr. Lacouture was gracious enough to share some of his expertise with us in a webinar program he did with us last year, and the podcast from that is available here.  

Dr. Lacouture has distilled his vast experience into a very practical book that he was kind enough to send me a copy of, and which is now an extremely valuable reference guide in my clinic:  ”Dr. Lacouture’s Skin Care Guide for People Living with Cancer“.  I strongly recommend it for anyone with cancer who is struggling or may soon be struggling with issues with their skin (and it might just be a helpful reference for other people with dermatologic problems too).  There are two things that I think are especially helpful.  First, it is as comprehensive as you could hope to see for a book directed at the lay public.  It’s not necessarily meant to be a book you read from cover to cover at the beach (but if you do, please wear sunscreen), but it has information for just about every real problem people face, and you can hone right in on it in the relevant chapter or through the index.   Second, it’s written in remarkably accessible language, with tables and figures and detailed descriptions of how and where to find actual products that can help.    This book is very, very practical.  

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Selected ASCO Abstracts on Treating Treatment-Induced Toxicity

Compared with novel treatments for different cancers, research relating to therapy of treatment-related toxicities often suffers in terms of “softer” endpoints that are subjective in nature (rather than objective endpoints like tumor shrinkage or time to disease progression that can be more easily measured) and small sample sizes limiting the generalizability of the information to different patient populations.  As with any therapy, patients and medical team members must weigh risk and benefit, but this is especially important when using a drug to treat a drug-related toxicity.  However, as our therapies get better at controlling cancer, keeping therapy tolerable becomes ever more important.  Below I will highlight some selected abstracts that showed benefits for some common treatment-related toxicities.

 

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Can You Get “Chemo-Brain” Without Getting Chemo?

Cognitive dysfunction among cancer survivors, particularly breast cancer survivors has received increased attention in recent years and is frequently referred to as “chemobrain” as patients view it as a side effect of their chemotherapy. This term became popular after women with breast cancer began noticing mental “fogginess”, concentration issues and memory difficulties beginning around the time they were being treated with chemotherapy. Breast cancer however is rarely treated with chemotherapy alone. As a result, chemobrain is a poor name for this issue as it is undoubtedly caused by a wide variety of factors in addition to chemotherapy including the impacts of surgery and anesthesia, menopause, hormonal therapy, fatigue, depression, and supportive care medications, to name just a few. It is likely more accurately labeled “cancer or cancer-therapy-associated cognitive dysfunction” but unfortunately that isn’t nearly as catchy of a name as chemobrain.

Typical complaints reported by patients with cancer and cognitive dysfunction include memory difficulties, difficulty concentrating on a task, difficulty remembering details such as names, dates, phone numbers, and difficulty multitasking. These complaints are associated with a measurable decline on cognitive testing. In the past, however studies have been small and they differed in their definition and measurement of cognitive dysfunction making it difficult, if not impossible to compare studies.

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The Biology of Aspirin

There is newfound excitement in the world of cancer over the role of aspirin, thanks to a recent study in the journal Lancet on the chemopreventive effects of aspirin.  This article was published on the heels of a media frenzy surrounding the invention of a new “super aspirin” called NOSH-aspirin.   Because of all the renewed interest in a century old drug, we thought it would be a good time to revisit the biology of aspirin for those of you who may be interested.  Aspirin is one member of a drug class called non-steroidal anti-inflammatory drugs, or NSAIDs.  Aspirin is primarily used as an analgesic (pain-reliever) and an anti-inflammatory drug.  The effects of aspirin in combatting pain and inflammation arise through the ability of aspirin to inhibit the formation of a molecule called prostaglandin 2, PGE2. 

PGE2 is an important signaling molecule in your body that can cause all sorts of physiological effects from muscle contraction to pain and blood clotting.  Aspirin blocks PGE2 to relieve pain and prevent inflammation by thinning your blood, among other things.  Aspirin blocks PGE2 by directly inhibiting cells from making PGE2, a function which is normally carried out by the enzyme cyclooxygenase (COX).  There are two main forms of cycooxygenase in the body, COX-1 and COX-2.  Aspirin is capable of inhibiting both COX-1 and COX-2, depending on the dose, and it can exert a great effect in cells like blood cells because platelets can’t regenerate COX once it is rendered dysfunctional by aspirin.  This is helpful for the blood thinning functions of aspirin such as preventing stroke, but this is also where the serious bleeding side effects of aspirin are derived.  Further, PGE2 has known protective effects in the gastrointestinal tract which is why many people suffer gastrointestinal irritations with frequent aspirin use.

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Hematopoiesis (Creating New Blood Cells) and Growth Factors

There are numerous types of cells that make up the bone marrow, each with their own specific function.  I’m going to focus on the three most commonly affected by chemotherapy: neutrophils (white blood cells), erythrocytes (red blood cells, measured by hemoglobin or hematocrit) and platelets (blood clotting cells).  These cells are born primarily in the bone marrow and then eventually leave the bone marrow to circulate in the peripheral blood.  When your blood is drawn in the clinic, the number that comes back reflects the number of each particular cell in the peripheral blood.  Each of these cells starts out as an immature stem cell that has the potential to be any type of blood cell.  However, what type of cell the immature cell becomes depends on the type of growth factor that acts upon it.  For example, if the body senses it needs more red blood cells, it will release more erythropoietin which will tell more of the stem cells to become erythrocytes which will mature in red blood cells.  

Growth Factor

Immature cell

Adult cell

What they do

Granuloctype colony stimulating factor(G-CSF)

Myelocyte

Leukocyte/Neutrophil (White blood cell)

Fight infection

Erythropoietin

Reticulocyte

Red blood cell

Carry oxygen

Thrombopoietin

Megakaryocyte

Platelet

Help blood clot

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