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QOL Considerations in Advanced Pancreatic Cancer

Insights From:Thomas A. Abrams, MD, Harvard Medical School; Johanna Bendell, MD, Sarah Cannon Research Institute; George P. Kim, MD, 21st Century Oncology; Caio Rocha Lima, MD, Gibbs Cancer Center and Research Institute; Philip A. Philip, MD, PhD, FRCP, Wayne State University
Published: Tuesday, Mar 22, 2016


Transcript:

Caio Rocha Lima, MD:
One of the things that was clear to me with the ACCORD 11 trial was the importance of chemotherapy in this disease. We underestimate this because of the relatively low response rates and the outcome of the disease. When we look at one of the few trials we have in pancreatic cancer, it actually has quality of life in it. They measured the degradation of quality of life because most of the patients had good quality of life to start with. They select perfect organ function patients, what we call performance status 0 to 1. As the patients progress, their quality of life starts to drop to where it’s almost a parallel curve. This tells me that the patient’s quality of life did not drop because of the toxicity; it dropped because of cancer progression.

And in pancreatic cancer, we all see the curves. You have this narrow drop that soon after the curve takes off, it drops and then it levels off. It’s important that one cannot wait too long to go into second-line treatment because the quality of life drops very quickly as they progress. The patients tend to say, “Oh, maybe I should take a break.” We should be very cautious about that. I like the approach that I’m giving the patient on break with a non-cross–toxicity regimen. You are getting away from a regimen where the neuropathy is reversible most of the time, with nab-paclitaxel, but you have neuropathy. And you go to a regimen that has no neuropathy.

Philip A. Philip, MD, PhD, FRCP: We have to be careful. If you have a very chemo-sensitive disease or lightly chemo-sensitive disease, you can mitigate the worsening of the performance status. But you really have to have a disease where chemotherapy gives you response rates of maybe 30%, 40%, to really have that. In pancreatic cancer, in the NAPOLI-1 trial, the response rate, if I remember correctly, was 16%, and that’s in a select group of patients. We don’t have regimens that we can use in the second-line thinking, that I’m just going to use to reverse the downward trend of the quality of life or the performance status. In fact, my concern is, you can make it worse. For what is the gain of a few weeks or a month or two? If a patient wants to go through it, I don’t have a problem. Really, the expectations have to be way down in the patient, but also we have to support them better. I mean, we go back to supportive care, but we don’t do a very good job in supportive care.

Thomas A. Abrams MD: That’s a really important point. Excellent supportive care and keeping patients from impacts of the symptoms that they’re having is going to play a huge role in what you can give them for chemotherapy and, ultimately, what the response is going to be. It is at least as important to choose the right chemotherapy as it is to try to get their symptoms under control. I agree that we don’t necessarily do the best job that we can there.

Philip A. Philip, MD, PhD, FRCP: I agree.

George P. Kim, MD: You’ve got to get your nurse practitioners in there. You’re got to get your chemotherapy nurses in there. You’ve got to get your palliative care people in there. You’ve got to have them fully supportive. So I absolutely agree.

Philip A. Philip, MD, PhD, FRCP: I do not use the word “palliative” because palliative doesn’t work. It’s not a word that you want to use here. If you really want to implement this, use “supportive care” because that’s much more acceptable. Because palliative care somehow links to hospice and you don’t want to. It’s semantics, but the reality is that.

George P. Kim, MD: There’s no harm in using the word “hospice,” and there are studies from Yale that show if you introduce hospice early on, patients have a better mind, they’re more at peace, and their quality of life also goes up. Let’s not be afraid of what happens to our advanced cancer patients.

Philip A. Philip, MD, PhD, FRCP: In England, when we had outpatient hospice, which was implemented early on, you go to hospice, you go out of other care.

Johanna Bendell, MD: Certainly, the data are starting to come around, within the United States, of the importance of having the supportive care or palliative care, either one, and patient-centered care that’s involved with chemotherapy.

Thomas A. Abrams, MD: That’s our job. It’s a continuum of care. It’s not black-or-white, and we tend to make an artificial distinction between palliative care and oncology when it’s two sides of the same coin. But it is a continuum, and we have to be great at both.

Transcript Edited for Clarity
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Transcript:

Caio Rocha Lima, MD:
One of the things that was clear to me with the ACCORD 11 trial was the importance of chemotherapy in this disease. We underestimate this because of the relatively low response rates and the outcome of the disease. When we look at one of the few trials we have in pancreatic cancer, it actually has quality of life in it. They measured the degradation of quality of life because most of the patients had good quality of life to start with. They select perfect organ function patients, what we call performance status 0 to 1. As the patients progress, their quality of life starts to drop to where it’s almost a parallel curve. This tells me that the patient’s quality of life did not drop because of the toxicity; it dropped because of cancer progression.

And in pancreatic cancer, we all see the curves. You have this narrow drop that soon after the curve takes off, it drops and then it levels off. It’s important that one cannot wait too long to go into second-line treatment because the quality of life drops very quickly as they progress. The patients tend to say, “Oh, maybe I should take a break.” We should be very cautious about that. I like the approach that I’m giving the patient on break with a non-cross–toxicity regimen. You are getting away from a regimen where the neuropathy is reversible most of the time, with nab-paclitaxel, but you have neuropathy. And you go to a regimen that has no neuropathy.

Philip A. Philip, MD, PhD, FRCP: We have to be careful. If you have a very chemo-sensitive disease or lightly chemo-sensitive disease, you can mitigate the worsening of the performance status. But you really have to have a disease where chemotherapy gives you response rates of maybe 30%, 40%, to really have that. In pancreatic cancer, in the NAPOLI-1 trial, the response rate, if I remember correctly, was 16%, and that’s in a select group of patients. We don’t have regimens that we can use in the second-line thinking, that I’m just going to use to reverse the downward trend of the quality of life or the performance status. In fact, my concern is, you can make it worse. For what is the gain of a few weeks or a month or two? If a patient wants to go through it, I don’t have a problem. Really, the expectations have to be way down in the patient, but also we have to support them better. I mean, we go back to supportive care, but we don’t do a very good job in supportive care.

Thomas A. Abrams MD: That’s a really important point. Excellent supportive care and keeping patients from impacts of the symptoms that they’re having is going to play a huge role in what you can give them for chemotherapy and, ultimately, what the response is going to be. It is at least as important to choose the right chemotherapy as it is to try to get their symptoms under control. I agree that we don’t necessarily do the best job that we can there.

Philip A. Philip, MD, PhD, FRCP: I agree.

George P. Kim, MD: You’ve got to get your nurse practitioners in there. You’re got to get your chemotherapy nurses in there. You’ve got to get your palliative care people in there. You’ve got to have them fully supportive. So I absolutely agree.

Philip A. Philip, MD, PhD, FRCP: I do not use the word “palliative” because palliative doesn’t work. It’s not a word that you want to use here. If you really want to implement this, use “supportive care” because that’s much more acceptable. Because palliative care somehow links to hospice and you don’t want to. It’s semantics, but the reality is that.

George P. Kim, MD: There’s no harm in using the word “hospice,” and there are studies from Yale that show if you introduce hospice early on, patients have a better mind, they’re more at peace, and their quality of life also goes up. Let’s not be afraid of what happens to our advanced cancer patients.

Philip A. Philip, MD, PhD, FRCP: In England, when we had outpatient hospice, which was implemented early on, you go to hospice, you go out of other care.

Johanna Bendell, MD: Certainly, the data are starting to come around, within the United States, of the importance of having the supportive care or palliative care, either one, and patient-centered care that’s involved with chemotherapy.

Thomas A. Abrams, MD: That’s our job. It’s a continuum of care. It’s not black-or-white, and we tend to make an artificial distinction between palliative care and oncology when it’s two sides of the same coin. But it is a continuum, and we have to be great at both.

Transcript Edited for Clarity
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Online CME Activities
TitleExpiration DateCME Credits
Oncology Briefings™: Integrating Novel Targeted Treatment Strategies to Advance Pancreatic Cancer CareNov 30, 20181.0
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