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Palliative Care Recommendations in Pancreas Cancer

Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Winson Y. Cheung, MD, MPH, University of Calgary and CancerControl Alberta; Manuel Hidalgo, MD, PhD, Harvard Medical School and Beth Israel Deaconess Medical Center; Ramesh K. Ramanathan, MD, Mayo Clinic; Tanios Bekaii-Saab, MD, FACP, Mayo Clinic; Thomas Seufferlein, MD, University of Ulm
Published: Tuesday, Oct 24, 2017



Transcript:

Johanna C. Bendell, MD: We talk about the supportive care for pancreas cancer patients, but it’s very complicated. Pancreas cancer patients have a lot going on from their disease and how they’re feeling. How do we maximize their performance status and maximize their quality of life to be able to receive treatment but also to improve survival, which we know that when your quality of life is better, you live longer? So, Winson, when you see a patient with pancreas cancer, what are some of your secret tricks or drugs that you use to help maximize their quality of life?

Winson Y. Cheung, MD, MPH: Well, I think we have to take a step back and also remind ourselves that even though there has been advances in these therapeutic options, at the end of the day, these are still palliative intent therapies. I think quality of life and symptom control are paramount in terms of the overall goal of comprehensive cancer care. At our centers, in addition to using certain drugs, we engage palliative care very, very early on. Usually during the first or second visit, we involve it. There are some patients who are really good (ECOG 0) and don’t need the services right away. But just putting them in touch is really, really helpful. That, to me, is the most important step of all: to engage the right people from the very beginning.

Johanna C. Bendell, MD: And that’s actually based on work that was done out of the Harvard system. It was beautiful work. It started with non–small cell lung cancer patients, and I just love this paper from The New England Journal of Medicine. When you bring a palliative care physician in with a medical oncologist from the beginning, as compared to a medical oncologist alone, the survival curves look even better than some of the survival curves that we see with chemotherapy favoring having that supportive care. I joke, Thomas, that you guys are so tough in Germany. But tell us, what are some of your secrets to helping these patients feel better? Do you have palliative care? And what do you do, maybe, outside of palliative care?

Thomas Seufferlein, MD: We have palliative care involved very early on, and we have a different system because patients are more attached to centers. We don’t have long distances. This is much more regional care, which makes a lot of sense and is an advantage to patients. We even have an outpatient palliative care system where patients are really cared for at home. We do quite a bit of parenteral nutrition in case patients cannot provide themselves with enough food. Even enteral nutrition doesn’t work in the support, but we really care very early on. As Winson said, we would do that even after the second visit and also for psycho-oncology, not only for nutritional purposes, but also for psychological purposes. This is a multidisciplinary team that’s very much involved in taking care of patients, and this really benefits patients. And nutrition, I think, is an issue which is undervalued, still, and we should do more about that, definitely.

Johanna C. Bendell, MD: Yes. I’m a huge fan of steroids, especially in the pancreas patients, though you have to be wary that a lot of them will have diabetes. But that’s one of my trick drugs if I don’t have palliative care immediately available or if I’m seeing them first. It seems to make people eat better and feel better. Tell us, Tony, what do you do?

Tanios Bekaii-Saab, MD, FACP: We have palliative care embedded into our practice, but I do agree. I’ve turned around a lot of patients with a low-dose steroid—a simple 5-mg, 10-mg prednisone regimen and then I put them back on therapy. To Manuel’s point, I think the most important piece that a lot of physicians and medical oncologists miss is that they essentially assign the wrong performance status to a patient who is actually low performance but symptomatic. If you can control the symptoms, you get them to feel better. Then, they are more eligible for more aggressive treatment. And that may explain why the introduction of palliative care, early, improved survival. Those patients actually were able to get more aggressive treatment. And many times, especially in pancreas cancer, a lot of patients get the disservice of being sent, early, to hospice. They are not exposed to adequate treatment because of misidentifying the performance status and not involving palliative care ahead of time, really early in the game.

Johanna C. Bendell, MD: Ramesh, do you have any secret clinical pearls to give here?

Ramesh K. Ramanathan, MD: I think it’s important to identify patients where things can be reversed. One is gastric outlet obstruction, which I frequently see attributed to the chemotherapy or the cancer. But that’s actually a mechanical obstruction where stenting or even a gastrojejunostomy, in some cases, can help. Also, pancreatic insufficiency is frequently undertreated.

Johanna C. Bendell, MD: Yes.

Ramesh K. Ramanathan, MD: I think probably 95% of patients need pancreatic enzymes.

Manuel Hidalgo, MD, PhD: They do, yes.

Ramesh K. Ramanathan, MD: But maybe 20% get it.

Johanna C. Bendell, MD: Or they’re underdosed.

Manuel Hidalgo, MD, PhD: The other thing that has been very interesting to me, as I have moved from Europe to the United States (I live in Massachusetts), is the use of medical marijuana in our system. Many patients are using that and are prescribed that. It increases appetite. It decreases symptoms. It controls diarrhea. I think it’s useful. It’s useful, and many patients use it.

Johanna C. Bendell, MD: I’m just jealous because I live in Tennessee.

Tanios Bekaii-Saab, MD, FACP: We have it, but it’s not in our pathway.

Ramesh K. Ramanathan, MD: I think a lot of patients don’t tell you that they’re on medical marijuana. I’m a little concerned about drug–drug interactions.

Manuel Hidalgo, MD, PhD: No, for us, it’s a very well-established system. You have it and everything is known.

Tanios Bekaii-Saab, MD, FACP: Are you able to prescribe it in your system?

Manuel Hidalgo, MD, PhD: No. We can if we want, but you need to get a special license. The easiest thing to do is to refer the patient to a medical marijuana dispensary where a nurse and a doctor would prescribe it and manage the patient. But you get the dose that they’re taking; it’s all done. There are no secrets. Sometimes they use it and like it better than the classic tetrahydrocannabinol. The component doesn’t have the neurological effects. The patients don’t get the neurological or psychological effects. They see more bowel improvement.

Thomas Seufferlein, MD: You’re raising an important point, Manuel, because I think another issue that is undervalued is pain management. Patients tend to not discuss, or underreport, pain. You have to ask them to really get an appropriate answer. They say, “Everything is fine, everything is fine.” I say, “Do you have pain?” “Well, yes, a bit.” And I say, “Well, you do have a scale?” “Well, 7 out of 10, maybe 8, but only during short times of the day.”

If they have pain, they don’t eat. If they don’t eat, they lose weight and they deteriorate in ECOG. So, I think really getting a grasp on pain management is an important point. Of course, that’s what you say in having the whole system in mind, bowel movement, etc. I think this is very important, and we need to really press on that. Patients tend to under report.

Johanna C. Bendell, MD: They get worried that they’re going to get addicted to pain medicine.

Thomas Seufferlein, MD: Exactly.

Johanna C. Bendell, MD: And I keep trying to convince them that they’re not. Sometimes I tell them that there have been studies that show when you have good pain control, you have less fatigue. Usually they’ll say, “Really? Maybe I’ll take my pain medicine.” But yes, we need to look at the whole patient and make sure we have a comprehensive approach.

Transcript Edited for Clarity 

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Transcript:

Johanna C. Bendell, MD: We talk about the supportive care for pancreas cancer patients, but it’s very complicated. Pancreas cancer patients have a lot going on from their disease and how they’re feeling. How do we maximize their performance status and maximize their quality of life to be able to receive treatment but also to improve survival, which we know that when your quality of life is better, you live longer? So, Winson, when you see a patient with pancreas cancer, what are some of your secret tricks or drugs that you use to help maximize their quality of life?

Winson Y. Cheung, MD, MPH: Well, I think we have to take a step back and also remind ourselves that even though there has been advances in these therapeutic options, at the end of the day, these are still palliative intent therapies. I think quality of life and symptom control are paramount in terms of the overall goal of comprehensive cancer care. At our centers, in addition to using certain drugs, we engage palliative care very, very early on. Usually during the first or second visit, we involve it. There are some patients who are really good (ECOG 0) and don’t need the services right away. But just putting them in touch is really, really helpful. That, to me, is the most important step of all: to engage the right people from the very beginning.

Johanna C. Bendell, MD: And that’s actually based on work that was done out of the Harvard system. It was beautiful work. It started with non–small cell lung cancer patients, and I just love this paper from The New England Journal of Medicine. When you bring a palliative care physician in with a medical oncologist from the beginning, as compared to a medical oncologist alone, the survival curves look even better than some of the survival curves that we see with chemotherapy favoring having that supportive care. I joke, Thomas, that you guys are so tough in Germany. But tell us, what are some of your secrets to helping these patients feel better? Do you have palliative care? And what do you do, maybe, outside of palliative care?

Thomas Seufferlein, MD: We have palliative care involved very early on, and we have a different system because patients are more attached to centers. We don’t have long distances. This is much more regional care, which makes a lot of sense and is an advantage to patients. We even have an outpatient palliative care system where patients are really cared for at home. We do quite a bit of parenteral nutrition in case patients cannot provide themselves with enough food. Even enteral nutrition doesn’t work in the support, but we really care very early on. As Winson said, we would do that even after the second visit and also for psycho-oncology, not only for nutritional purposes, but also for psychological purposes. This is a multidisciplinary team that’s very much involved in taking care of patients, and this really benefits patients. And nutrition, I think, is an issue which is undervalued, still, and we should do more about that, definitely.

Johanna C. Bendell, MD: Yes. I’m a huge fan of steroids, especially in the pancreas patients, though you have to be wary that a lot of them will have diabetes. But that’s one of my trick drugs if I don’t have palliative care immediately available or if I’m seeing them first. It seems to make people eat better and feel better. Tell us, Tony, what do you do?

Tanios Bekaii-Saab, MD, FACP: We have palliative care embedded into our practice, but I do agree. I’ve turned around a lot of patients with a low-dose steroid—a simple 5-mg, 10-mg prednisone regimen and then I put them back on therapy. To Manuel’s point, I think the most important piece that a lot of physicians and medical oncologists miss is that they essentially assign the wrong performance status to a patient who is actually low performance but symptomatic. If you can control the symptoms, you get them to feel better. Then, they are more eligible for more aggressive treatment. And that may explain why the introduction of palliative care, early, improved survival. Those patients actually were able to get more aggressive treatment. And many times, especially in pancreas cancer, a lot of patients get the disservice of being sent, early, to hospice. They are not exposed to adequate treatment because of misidentifying the performance status and not involving palliative care ahead of time, really early in the game.

Johanna C. Bendell, MD: Ramesh, do you have any secret clinical pearls to give here?

Ramesh K. Ramanathan, MD: I think it’s important to identify patients where things can be reversed. One is gastric outlet obstruction, which I frequently see attributed to the chemotherapy or the cancer. But that’s actually a mechanical obstruction where stenting or even a gastrojejunostomy, in some cases, can help. Also, pancreatic insufficiency is frequently undertreated.

Johanna C. Bendell, MD: Yes.

Ramesh K. Ramanathan, MD: I think probably 95% of patients need pancreatic enzymes.

Manuel Hidalgo, MD, PhD: They do, yes.

Ramesh K. Ramanathan, MD: But maybe 20% get it.

Johanna C. Bendell, MD: Or they’re underdosed.

Manuel Hidalgo, MD, PhD: The other thing that has been very interesting to me, as I have moved from Europe to the United States (I live in Massachusetts), is the use of medical marijuana in our system. Many patients are using that and are prescribed that. It increases appetite. It decreases symptoms. It controls diarrhea. I think it’s useful. It’s useful, and many patients use it.

Johanna C. Bendell, MD: I’m just jealous because I live in Tennessee.

Tanios Bekaii-Saab, MD, FACP: We have it, but it’s not in our pathway.

Ramesh K. Ramanathan, MD: I think a lot of patients don’t tell you that they’re on medical marijuana. I’m a little concerned about drug–drug interactions.

Manuel Hidalgo, MD, PhD: No, for us, it’s a very well-established system. You have it and everything is known.

Tanios Bekaii-Saab, MD, FACP: Are you able to prescribe it in your system?

Manuel Hidalgo, MD, PhD: No. We can if we want, but you need to get a special license. The easiest thing to do is to refer the patient to a medical marijuana dispensary where a nurse and a doctor would prescribe it and manage the patient. But you get the dose that they’re taking; it’s all done. There are no secrets. Sometimes they use it and like it better than the classic tetrahydrocannabinol. The component doesn’t have the neurological effects. The patients don’t get the neurological or psychological effects. They see more bowel improvement.

Thomas Seufferlein, MD: You’re raising an important point, Manuel, because I think another issue that is undervalued is pain management. Patients tend to not discuss, or underreport, pain. You have to ask them to really get an appropriate answer. They say, “Everything is fine, everything is fine.” I say, “Do you have pain?” “Well, yes, a bit.” And I say, “Well, you do have a scale?” “Well, 7 out of 10, maybe 8, but only during short times of the day.”

If they have pain, they don’t eat. If they don’t eat, they lose weight and they deteriorate in ECOG. So, I think really getting a grasp on pain management is an important point. Of course, that’s what you say in having the whole system in mind, bowel movement, etc. I think this is very important, and we need to really press on that. Patients tend to under report.

Johanna C. Bendell, MD: They get worried that they’re going to get addicted to pain medicine.

Thomas Seufferlein, MD: Exactly.

Johanna C. Bendell, MD: And I keep trying to convince them that they’re not. Sometimes I tell them that there have been studies that show when you have good pain control, you have less fatigue. Usually they’ll say, “Really? Maybe I’ll take my pain medicine.” But yes, we need to look at the whole patient and make sure we have a comprehensive approach.

Transcript Edited for Clarity 
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