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Optimizing Care to Avoid CINV

Panelists:Lee S. Schwartzberg, MD, FACP, University of Tennessee Health Science Center;Rebecca Clark-Snow, RN, BSN, OCN, University of Kansas Cancer Center;Charles L. Loprinzi, MD, Mayo Clinic;James Natale, PharmD, BCOP, UPMC Cancer Center;Eric Roeland, MD, University of California, San Diego
Published: Thursday, Sep 29, 2016


Transcript:

Lee S. Schwartzberg, MD:
I want to talk a minute about the team and how we use the team together. We’ve got a lot of expertise from different areas on this panel. How do we work together better to take care of our patients and prevent CINV? Let me start with you, Jim.

James Natale, PharmD, BCOP: Well, at our institution, from a pharmacy perspective, we are really involved in global order writing from putting frontloading in the EMR with this regimen. This is what we recommend from an antiemetic perspective. And then, on a direct patient care basis, we’re integrated in all of the teaching services and routing services, as well as in the outpatient clinics. So, we’ve reviewed those patients prior to coming in. We make those phone calls to a patient saying, “How’d you tolerate your last cycle of chemotherapy?”

Lee S. Schwartzberg, MD: So, you make the phone calls? The pharmacists make them?

James Natale, PharmD, BCOP: The pharmacist, yes. We do make some of those phone calls. Not all of them, but certainly for those patients who had problems in the past, or are high risk, we will make those phone calls. We do try to have an integrated talk with our nursing staff because it seems like they trust the nurses the most to tell them what really happened with the last cycle of chemotherapy. We would work with them and the medical staff, as well, to come up, especially if we have to change from what’s loaded into the EMR.

Lee S. Schwartzberg, MD: What about from the nurses’ perspective, Rebecca?

Rebecca Clark-Snow, RN, BSN, OCN: Just reiterating the same thing. It’s truly a multidisciplinary effort, working with the physicians, the pharmacists, the social workers, the nutritionists as well, our palliative care services. We’re all one community under one roof. So, that’s how it works.

James Natale, PharmD, BCOP: And, I would say social workers are vitally important as well, with all the different insurance programs out there and formularies that are out there. It is a challenge. Even if you want to use a certain regimen, sometimes you just can’t based on the patient’s insurance or other circumstances from a reimbursement standpoint.

Lee S. Schwartzberg, MD: Yes, I would definitely emphasize that. So, we have an emerging class of one of the team members, the financial counselors. And, I think the financial counselors here are very important, even when it comes to supportive care drugs.

Rebecca Clark-Snow, RN, BSN, OCN: Absolutely. Even before a patient starts their treatment, they need to meet with a financial counselor and go over a plan.

Lee S. Schwartzberg, MD: Right.

Eric Roeland, MD: I think the medical oncologist’s role here is to be humble. And the reason why is we’re not necessarily always getting the information. So, if we don’t hear about it, I think our assumption is that it’s not a problem, and patients are afraid to tell us, even in this day and age. And so, if we’re hearing from our colleagues that our patients are worried about that, we need to trust them.

Lee S. Schwartzberg, MD: And, I think, maybe we need to level set better with our patients and tell them up front, and repeat to them, “Tell us about your symptoms. Your control of your cancer is not related to your symptoms. We can take care of your symptoms.” Do you have any thoughts? You’ve had a career in symptom management and made so many great advances.

Charles L. Loprinzi, MD: Listening to the nurses and the pharmacists, and then coming up with a plan together is important. The doctor can add a little bit to the process there. And, again, it is a team approach, I agree.

Eric Roeland, MD: I think a key message for a medical oncologist to deliver is that suffering doesn’t have to be in silence. We can control your symptoms and still be optimally aggressive about your care. Patients who feel better live longer. And so, I think those are the kinds of things that I try to tell them, and repeat, so that they’re not just suffering at home alone.

James Natale, PharmD, BCOP: And, also, I think the team is not just your team. We certainly are a referral center. Oftentimes we have to call the community oncologist or vice versa to get information and see how patients did, or what other information you need to make sure that you’re taking care of them appropriately. The teams are getting bigger now, as care’s being broadened across the community as well as academic institutions.

Lee S. Schwartzberg, MD: So, it really does take a village to take care of a cancer patient. And as care gets more and more complex, we have to add more people. It adds more cost, but we’re doing better, we’re controlling symptoms, and we’re actually having patients live longer.

Rebecca Clark-Snow, RN, BSN, OCN: Absolutely.

Lee S. Schwartzberg, MD: This has been extremely informative. We’ve talked about several new therapeutic options. We’ve talked a number of everyday clinical scenarios that hopefully will help our audience and will shed light on ways to improve CINV management in your practice. Before we end this discussion, I’d like to get final thoughts from each of our panelists. Rebecca?

Rebecca Clark-Snow, RN, BSN, OCN: So, as an oncology nurse, and one that’s been practicing for about 40 years, I believe that we are symptom managers. We are educators. And communication is key, providing all the information that we have for our patients and then to discuss it with our team, once again, to make sure the patients have the best possible outcomes. I can clearly say we’ve come a long way from years gone past. We have a ways to go still, but I believe that someday we’ll reach that goal of hopefully having no nausea or vomiting for our patients. We certainly can use the guidelines appropriately to provide our patients with the best care possible.

Lee S. Schwartzberg, MD: Thank you. Charles?

Charles L. Loprinzi, MD: I agree. I think we’re doing much, much better than we were 20 or 30 years ago. There’s room for improvement. But, in 10 years and 15 years from now, there will always be room for improvement. As you understand more things, you just say, “What’s the next step, what more can we make?” So, we’ll never be a nirvana I don’t think. There’s always going to be a role for us to make things better as we go along.

Lee S. Schwartzberg, MD: Thank you. Jim?

James Natale, PharmD, BCOP: I tell my residents and fellows actually, this has probably been one of the biggest success stories in oncology. If you go back to the original platinum, back when there was just high-dose Reglan or steroids, where really 1 out of 2 people had problems with emesis, to now the 3-drug regimens, we’re well into the 95% control rate. But, Charles, as you mentioned, there’s always going to be room to improve, and I do think there are some unmet needs that we’ve discussed today. We certainly made great advances in this area and we need to continue to do so.

Lee S. Schwartzberg, MD: Thank you. Eric?

Eric Roeland, MD: I think the key message is that there are a lot of new tools out there. Just like we have a lot of new tools in oncology, there are new tools in this area. And, if you’re not necessarily familiar with them, find someone who is. I don’t think patients and loved ones should be just at home suffering. Let us know because we all sincerely want to help you get through your treatment so we can be as aggressive as possible.

Lee S. Schwartzberg, MD: Thank you. So, we’re here to help. We have tools. We’ve made tremendous strides in CINV, and we still have some ways to go. I want to thank all of the panelists for your contributions. It’s really been a fantastic discussion. I really appreciate it. On behalf of our panel, we thank you for joining us and we hope you found this Peer Exchange discussion to be useful and informative. Thank you.

Transcript Edited for Clarity
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Transcript:

Lee S. Schwartzberg, MD:
I want to talk a minute about the team and how we use the team together. We’ve got a lot of expertise from different areas on this panel. How do we work together better to take care of our patients and prevent CINV? Let me start with you, Jim.

James Natale, PharmD, BCOP: Well, at our institution, from a pharmacy perspective, we are really involved in global order writing from putting frontloading in the EMR with this regimen. This is what we recommend from an antiemetic perspective. And then, on a direct patient care basis, we’re integrated in all of the teaching services and routing services, as well as in the outpatient clinics. So, we’ve reviewed those patients prior to coming in. We make those phone calls to a patient saying, “How’d you tolerate your last cycle of chemotherapy?”

Lee S. Schwartzberg, MD: So, you make the phone calls? The pharmacists make them?

James Natale, PharmD, BCOP: The pharmacist, yes. We do make some of those phone calls. Not all of them, but certainly for those patients who had problems in the past, or are high risk, we will make those phone calls. We do try to have an integrated talk with our nursing staff because it seems like they trust the nurses the most to tell them what really happened with the last cycle of chemotherapy. We would work with them and the medical staff, as well, to come up, especially if we have to change from what’s loaded into the EMR.

Lee S. Schwartzberg, MD: What about from the nurses’ perspective, Rebecca?

Rebecca Clark-Snow, RN, BSN, OCN: Just reiterating the same thing. It’s truly a multidisciplinary effort, working with the physicians, the pharmacists, the social workers, the nutritionists as well, our palliative care services. We’re all one community under one roof. So, that’s how it works.

James Natale, PharmD, BCOP: And, I would say social workers are vitally important as well, with all the different insurance programs out there and formularies that are out there. It is a challenge. Even if you want to use a certain regimen, sometimes you just can’t based on the patient’s insurance or other circumstances from a reimbursement standpoint.

Lee S. Schwartzberg, MD: Yes, I would definitely emphasize that. So, we have an emerging class of one of the team members, the financial counselors. And, I think the financial counselors here are very important, even when it comes to supportive care drugs.

Rebecca Clark-Snow, RN, BSN, OCN: Absolutely. Even before a patient starts their treatment, they need to meet with a financial counselor and go over a plan.

Lee S. Schwartzberg, MD: Right.

Eric Roeland, MD: I think the medical oncologist’s role here is to be humble. And the reason why is we’re not necessarily always getting the information. So, if we don’t hear about it, I think our assumption is that it’s not a problem, and patients are afraid to tell us, even in this day and age. And so, if we’re hearing from our colleagues that our patients are worried about that, we need to trust them.

Lee S. Schwartzberg, MD: And, I think, maybe we need to level set better with our patients and tell them up front, and repeat to them, “Tell us about your symptoms. Your control of your cancer is not related to your symptoms. We can take care of your symptoms.” Do you have any thoughts? You’ve had a career in symptom management and made so many great advances.

Charles L. Loprinzi, MD: Listening to the nurses and the pharmacists, and then coming up with a plan together is important. The doctor can add a little bit to the process there. And, again, it is a team approach, I agree.

Eric Roeland, MD: I think a key message for a medical oncologist to deliver is that suffering doesn’t have to be in silence. We can control your symptoms and still be optimally aggressive about your care. Patients who feel better live longer. And so, I think those are the kinds of things that I try to tell them, and repeat, so that they’re not just suffering at home alone.

James Natale, PharmD, BCOP: And, also, I think the team is not just your team. We certainly are a referral center. Oftentimes we have to call the community oncologist or vice versa to get information and see how patients did, or what other information you need to make sure that you’re taking care of them appropriately. The teams are getting bigger now, as care’s being broadened across the community as well as academic institutions.

Lee S. Schwartzberg, MD: So, it really does take a village to take care of a cancer patient. And as care gets more and more complex, we have to add more people. It adds more cost, but we’re doing better, we’re controlling symptoms, and we’re actually having patients live longer.

Rebecca Clark-Snow, RN, BSN, OCN: Absolutely.

Lee S. Schwartzberg, MD: This has been extremely informative. We’ve talked about several new therapeutic options. We’ve talked a number of everyday clinical scenarios that hopefully will help our audience and will shed light on ways to improve CINV management in your practice. Before we end this discussion, I’d like to get final thoughts from each of our panelists. Rebecca?

Rebecca Clark-Snow, RN, BSN, OCN: So, as an oncology nurse, and one that’s been practicing for about 40 years, I believe that we are symptom managers. We are educators. And communication is key, providing all the information that we have for our patients and then to discuss it with our team, once again, to make sure the patients have the best possible outcomes. I can clearly say we’ve come a long way from years gone past. We have a ways to go still, but I believe that someday we’ll reach that goal of hopefully having no nausea or vomiting for our patients. We certainly can use the guidelines appropriately to provide our patients with the best care possible.

Lee S. Schwartzberg, MD: Thank you. Charles?

Charles L. Loprinzi, MD: I agree. I think we’re doing much, much better than we were 20 or 30 years ago. There’s room for improvement. But, in 10 years and 15 years from now, there will always be room for improvement. As you understand more things, you just say, “What’s the next step, what more can we make?” So, we’ll never be a nirvana I don’t think. There’s always going to be a role for us to make things better as we go along.

Lee S. Schwartzberg, MD: Thank you. Jim?

James Natale, PharmD, BCOP: I tell my residents and fellows actually, this has probably been one of the biggest success stories in oncology. If you go back to the original platinum, back when there was just high-dose Reglan or steroids, where really 1 out of 2 people had problems with emesis, to now the 3-drug regimens, we’re well into the 95% control rate. But, Charles, as you mentioned, there’s always going to be room to improve, and I do think there are some unmet needs that we’ve discussed today. We certainly made great advances in this area and we need to continue to do so.

Lee S. Schwartzberg, MD: Thank you. Eric?

Eric Roeland, MD: I think the key message is that there are a lot of new tools out there. Just like we have a lot of new tools in oncology, there are new tools in this area. And, if you’re not necessarily familiar with them, find someone who is. I don’t think patients and loved ones should be just at home suffering. Let us know because we all sincerely want to help you get through your treatment so we can be as aggressive as possible.

Lee S. Schwartzberg, MD: Thank you. So, we’re here to help. We have tools. We’ve made tremendous strides in CINV, and we still have some ways to go. I want to thank all of the panelists for your contributions. It’s really been a fantastic discussion. I really appreciate it. On behalf of our panel, we thank you for joining us and we hope you found this Peer Exchange discussion to be useful and informative. Thank you.

Transcript Edited for Clarity
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