In 2010, the world of lung cancer, and cancer in general, was abuzz with an intervention that improved quality of life and mood, and extended survival in patients with metastatic NSCLC. It was not a new chemotherapy or molecular biological agent. It was “early palliative care.”  The original New England Journal of Medicine article several months ago were covered by both Dr. West (here) and Dr. Ramchandran (here). A group from Massachusetts General Hospital (Harvard system), led by Jennifer Temel, conducted the study.

What exactly is “early palliative care”?  What exactly was happening in those visits?  Could it be replicated?  I’m a palliative care doctor, and I’ve been trying to figure this out myself.

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Following Dr. Lacouture’s presentation on management of skin, hair, and nail side effects of cancer treatments, we had a Q&A session from the audience.  This covered a lot of ground on a range of practical questions.  Here’s the audio podcast from that program, along with the transcript:

qa-dr-lacouture-on-skin-hair-nail-side-effects-of-treatment-transcript

This was really all audio without associated slides, so no figures or video version for this one.

Thanks again to LUNGevity Foundation for their partnership with GRACE in this program and the podcast. I hope it’s helpful.

Podcast: Play in new window | Download

Several weeks ago, Dr. Mario Lacouture, a dermatologist now on faculty and running a busy clinic at Memorial Sloan-Kettering Cancer Center, joined us to do a webinar on Healthy Skin for People Living with Lung Cancer: Managing Dermatologic Symptoms and Side Effects”.  I’m happy to now have the podcast from his presentation available, which is actually modified from the original one, since some of the slides and the overall presentation wasn’t as he wanted it to be, so he redid the recording and slides for the purposes of the podcast.  Therefore, for those who missed it, and even for those who attended, there should be new, practical information in there for you.  It covers prevention and treatment of problems involving skin, hair, and nails in cancer patients.

Below you’ll find the audio and video versions of the podcast, as well as a pdf file of the transcript and figures that go with it.

dr-lacouture-on-skin-hair-nail-side-effects-of-treatment-audio-podcast

dr-lacouture-on-skin-hair-nail-side-effects-of-treatment-transcript

dr-lacouture-on-skin-hair-nail-side-effects-of-treatment-figures

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Podcast: Play in new window | Download

What is a DVT and what is a PE?

DVT stands for deep vein thrombosis. “Thrombosis” is the doctorly word for, “clot,” and the deep veins are the larger veins of the legs and arms.

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Sometimes we find ourselves in a situation in cancer treatment where the choice of treatment options is almost the lesser of two evils.  For instance, a few months ago, a patient with locally advanced non-small cell lung cancer (NSCLC) showed little or no response to treatment with chemo and concurrent chest radiation that was intended to serve as pre-operative therapy before planned surgery for his stage IIIA NSCLC.  Unfortunately, we found that he still had viable cancer in his mediastinal (mid-chest) lymph nodes, which serve as a window to the status of the cancer elsewhere in the body and are very related to the risk of distant recurrence.  The general teaching is that people who still have viable cancer in their mediastinum after completing chemo/radiation tend to have an unfavorable prognosis that leads us to recommend against surgery for them.  But the problem is that they don’t tend to do any better with more of chemo and radiation for a cancer that has demonstrated its resistance to these modalities.  So it feels like you’re consigning someone to a very disappointing fate.

For this particular patient, I argued for consideration of surgery, on the premise that while the long term success rate of about 9% in this situation, based on the surgical literature, was better than an essentially 0% chance of success without it, and that this person was relatively young and fit.  Even if his cancer recurred after surgery, he would prefer to have had the opportunity, and I felt it was likely he’d tolerate the surgery far better than most patients.  Though his cancer recurred several months after surgery, despite my giving him additional chemotherapy in the adjuvant setting, neither of us felt regret for trying.

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Preventing F & N

There are three basic ways to prevent febrile neutropenia. When appropriate, a regimen with a smaller chance of causing F & N can be chosen. There are two other options: the use of drugs to bring the neutrophil count up, and prophylactic (preventative) antibiotics.

There are two drugs in common usage for lung cancer that can raise the neutrophil count. The first is called neupogen and the second neulasta. I’ve linked to the Amgen page on neulasta because I think that it’s actually pretty helpful. Granted, it’s there to sell more neulasta, but in trying to do so, the page on blood counts makes two very valid points about low blood counts: they can cause direct problems by causing infection, and they can interfere with needed chemotherapy.

How do these drugs work? As we discussed above, the bone marrow is a factory for making blood cells, including the subtype of white blood cells we’ve been talking about—neutrophils. Neupogen and neulasta send an artificial signal to the bone marrow to make more neutrophils, hurry up and get them ready, and release them into the blood. Neuopgen is given every day until the counts have recovered, typically a week or two. Neulasta is a long-acting drug that you only need to give once.

Both drugs, when utilized, are typically started 24 hours after chemotherapy. The package insert for both says that they shouldn’t be used for 14 days before chemotherapy. The reason for this is theoretical—doctors fear that if they send the bone marrow a signal for the blood-making stem cells to divide while chemo is still around, they will risk poisoning these stem cells, actually making the problem worse. This makes a lot of sense, but is it true? While coming back the next day is only a minor nuisance for some of my patients, for others it represents a significant hardship. What do the data say?

As usual, they are not definitive. Four randomized studies compared same day neulasta administration to the usual 24 hours post administration. Studies were done in patients with breast cancer, Non-Hodgkin’s lymphoma, NSCLC and ovarian CA. Overall, there was no clear harm from giving the neulasta the same day:

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Introduction

I have asked many patients what side effect of chemotherapy they fear the most. The most common answer is nausea, very closely followed by fatigue (or its cousins such as feeling, “blah,” or the consequences of fatigue such as not being able to do things). I’ve never asked the question of another oncologist, but I suspect that over half would respond, “F&N.”

F & N is not, “fresh and natural,” nor is it, “fries and nutella.” Rather, it’s, “febrile neutropenia.” What is this? Basically, it’s a fever, potentially indicating infection, at a time when blood counts are low.

As a patient, the most important thing to know if you should get a fever while on chemotherapy is to take it seriously. This should be seen as a top medical emergency prompting a visit to the ER and/or a call to your doctor. The reason is that the infections associated with febrile neutropenia can be extremely serious, and can progress quickly. This is not the time to spare your doctor a wake-up phone call in the middle of the night or to spare your partner having to get up and go to the ER. While these infections can be serious, when headed off quickly with IV antibiotics, most patients recover quite well. While definitions of fever vary, 100.4 Fahrenheit is a reasonable threshold.

But why should chemotherapy make blood counts low at all? Tumors grow through division of the cells that compose them. Chemotherapy works by killing rapidly dividing cells. Most cells in the adult body do not divide, and so are less affected by chemotherapy than cancer cells. However, there are a few places in the human body where cells normally divide and are thus affected by chemotherapy—the bone marrow is one of these places. The bone marrow is a factory where special cells called stem cells divide to make all the different kinds of blood cells. Chemotherapy temporarily lowers blood counts by shutting down the blood cell factory in the marrow. Occasionally, chemotherapy can even completely kill one of those stem cells, permanently reducing the speed at which the factory can produce cells. This is why following many cycles of chemotherapy, count recovery can become increasingly sluggish.

Types of blood cells

There are three basic types of cells in human blood: Platelets, red blood cells (aka erythrocytes), and white blood cells.

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This is a difficult topic for many people to think about, and especially to bring up in a public forum, but people still want and need to know what they might expect as they or someone they care for are declining.  It is understandable to fear the unknown, and to fear suffering.  I would say that there are a few leading points here:

1) Most patients don’t suffer much as their cancer progresses and as they transition through the dying process.

2) This process is quite variable from one person to another, but we typically have a good idea of what a patient’s leading problems will be weeks to months before a person is experiencing a more rapid decline.

3) Engaging hospice services/palliative care can help guide expectations and generally manage many of the problems effectively by anticipating them, rather than waiting until very late to accept palliative care.

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Hoarseness

Introduction

Thank you to cross-bearer for asking about hoarseness. Hoarseness is any change in voice quality. Most commonly, it is experienced as decreased volume with increased strain. It’s a common problem in lung cancer patients, so common that we’ve discussed it over 40 times in the forums and so I think that it may be time for a proper post discussing it.

There are many causes of hoarseness in the lung cancer patient. Many of these also happen in people without lung cancer, but all are more common in our circles either because of effects of the cancer itself, side effects of cancer treatments, or both.

Normal speech

Speech is produced in the voice box, or larynx.

External view of Larynx

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