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.
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 enjoying the content, we encourage you to rate us and review us on Apple Podcast.