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Supportive Care in Metastatic CRC

Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Cathy Eng, MD, FACP, The University of Texas MD Anderson Cancer Center; John L. Marshall, MD, The Ruesch Center for the Cure of GI Cancers ; Michael A. Morse, MD, Duke Cancer Institute; Dale R. Shepard, MD, PhD, FACP, Taussig Cancer Institute, Cleveland Clinic
Published: Monday, Apr 16, 2018



Transcript: 

John L. Marshall, MD: We go through lines of therapy, and we’re going to talk a little bit about subsequent lines of therapy in a minute. But I want to stop and talk about the patients who have done their oxaliplatin-based, irinotecan-based therapy. Now it’s 1 to 2 years later. How’s that patient different now?

Johanna C. Bendell, MD: They are tired.

John L. Marshall, MD: Tired?

Johanna C. Bendell, MD: Bald.

Cathy Eng, MD, FACP: I would hope that their hair would grow back at some point?

John L. Marshall, MD: I was hoping that, too.

Johanna C. Bendell, MD: Well, if you just used irinotecan, yes.

John L. Marshall, MD: So, what are they like?

Michael A. Morse, MD: Again, this speaks to biology. There are people who have made it out that far because they have more indolent disease. They’ve had good responses. Maybe they’ve been able to have a prolonged period of maintenance therapy? Maybe they could even stop maintenance therapy, temporarily? So, I think that those people are different from the ones in whom it seems like you’re going to the next line of therapy so quickly for. Those are definitely patients with a declining performance status.

Johanna C. Bendell, MD: What’s interesting, though, is that after those first 2 rounds of therapy, this is where the bottom falls out. They’ve been sort of trucking along, and they usually have a good response in the first-line setting and a pretty decent response in the second-line setting. I don’t know how much you discuss it with patients, but I find that they’re not quite prepared for the fact that things are about to take a turn for the worst, pretty fast.

John L. Marshall, MD: Yes, and I’m not sure that we do a very good job of this. We’re cheering them along, trying to be optimistic about next thoughts and clinical trials that we’ve got and all that stuff. I’m not sure that we do as good a job in that point of describing that transition. Do you all incorporate that into your discussions?

Cathy Eng, MD, FACP: I do. I really do think it’s important. I think it’s important that people understand that when you meet them, if they’re being treated for palliative therapy, it’s treating it like a chronic illness. And, at some point, things may change. We have to change with how their biology changes. Sometimes, it’s not always going to be favorable. It’s just a matter of really communicating with them, along the way, on the journey.

John L. Marshall, MD: Well, they’ve been on websites. They’ve talked, have gone to 5k races, and all of that. They are seeing those 4-, 5-, 6-year survivors. They want to be that person. Most of them aren’t going to be that person. You don’t want to beat them up with that, but you’ve got to sort of coach them through.

Dale R. Shepard, MD, PhD, FACP: I agree. From the beginning, I have the discussion that, at that point, we’re trying to control their tumor as best we can. We are trying to control their symptoms and make them live longer. With whatever therapies we have available—to your point about lines of therapy, Mike—patients like knowing that there are more things ahead. This is one of the reasons why I do VEGF therapies in the first- and second-line settings. You mentioned that they’re tired, right? I get tremendous clinical benefit from EGFR as a single agent in the third-line setting.

John L. Marshall, MD: And it’s kind of a rest period for them, too.

Dale R. Shepard, MD, PhD, FACP: Yes. Their liver function could be abnormal. It doesn’t matter. They can have cytopenias. It doesn’t matter. It’s actually a nice rest period. Exactly like you said, it’s a little break, before you get to more rigorous therapies.

John L. Marshall, MD: Should I have them go see palliative care right now?

Michael A. Morse, MD: I thought that it was interesting that you brought that up. The term palliative is one that is…

John L. Marshall, MD: We call it supportive care.

Michael A. Morse, MD: Supportive care.

Johanna C. Bendell, MD: Symptom management.

Michael A. Morse, MD: Sadly, we still call it palliative care, and the conversation doesn’t go very far, unfortunately.

John L. Marshall, MD: But is this the right time?

Michael A. Morse, MD: Actually, they’re in our clinic. We work very closely with them. As people get used to the idea that symptom control is as important as the longer survival and the responses that people still want to try to get, it is important that they have this availability of specialists that can focus on that.

Cathy Eng, MD, FACP: Coping. Coping mechanisms. The ability to help their family, manage sleep disorders. It’s about keeping the entire patient healthy—outside of what we do with chemotherapy.

John L. Marshall, MD: That sort of “Don’t forget to live” message is important here too.

Cathy Eng, MD, FACP: Definitely.

John L. Marshall, MD: You’re still slogging. But the reason that you’re doing this is to keep going. I wonder if guidelines would help. We get a lot of pressure, as oncologists, from our intensive care unit teams and all of that. We don’t do a good enough job of communicating this because we’re kind of on the cheerleading side. They’re on the Debbie Downer side, if you will. Maybe we draw this up as “This is when the recommended palliative care referral is”? But it would make sense, even if they’re asymptomatic.

Michael A. Morse, MD: An emerging area that I think will make this discussion easier is the whole concept of patient-reported outcomes and allowing patients to have a closer link, versus the way our medical records work now. To be able to report some of those symptoms and have them acted on more rapidly. There was a recent presentation and, now, published data on longer survival for people who engage in patient-reported outcome interactions.

John L. Marshall, MD: It is fabulous data. So, we should give them their Mediport and a Fitbit, right?

Transcript Edited for Clarity 

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Transcript: 

John L. Marshall, MD: We go through lines of therapy, and we’re going to talk a little bit about subsequent lines of therapy in a minute. But I want to stop and talk about the patients who have done their oxaliplatin-based, irinotecan-based therapy. Now it’s 1 to 2 years later. How’s that patient different now?

Johanna C. Bendell, MD: They are tired.

John L. Marshall, MD: Tired?

Johanna C. Bendell, MD: Bald.

Cathy Eng, MD, FACP: I would hope that their hair would grow back at some point?

John L. Marshall, MD: I was hoping that, too.

Johanna C. Bendell, MD: Well, if you just used irinotecan, yes.

John L. Marshall, MD: So, what are they like?

Michael A. Morse, MD: Again, this speaks to biology. There are people who have made it out that far because they have more indolent disease. They’ve had good responses. Maybe they’ve been able to have a prolonged period of maintenance therapy? Maybe they could even stop maintenance therapy, temporarily? So, I think that those people are different from the ones in whom it seems like you’re going to the next line of therapy so quickly for. Those are definitely patients with a declining performance status.

Johanna C. Bendell, MD: What’s interesting, though, is that after those first 2 rounds of therapy, this is where the bottom falls out. They’ve been sort of trucking along, and they usually have a good response in the first-line setting and a pretty decent response in the second-line setting. I don’t know how much you discuss it with patients, but I find that they’re not quite prepared for the fact that things are about to take a turn for the worst, pretty fast.

John L. Marshall, MD: Yes, and I’m not sure that we do a very good job of this. We’re cheering them along, trying to be optimistic about next thoughts and clinical trials that we’ve got and all that stuff. I’m not sure that we do as good a job in that point of describing that transition. Do you all incorporate that into your discussions?

Cathy Eng, MD, FACP: I do. I really do think it’s important. I think it’s important that people understand that when you meet them, if they’re being treated for palliative therapy, it’s treating it like a chronic illness. And, at some point, things may change. We have to change with how their biology changes. Sometimes, it’s not always going to be favorable. It’s just a matter of really communicating with them, along the way, on the journey.

John L. Marshall, MD: Well, they’ve been on websites. They’ve talked, have gone to 5k races, and all of that. They are seeing those 4-, 5-, 6-year survivors. They want to be that person. Most of them aren’t going to be that person. You don’t want to beat them up with that, but you’ve got to sort of coach them through.

Dale R. Shepard, MD, PhD, FACP: I agree. From the beginning, I have the discussion that, at that point, we’re trying to control their tumor as best we can. We are trying to control their symptoms and make them live longer. With whatever therapies we have available—to your point about lines of therapy, Mike—patients like knowing that there are more things ahead. This is one of the reasons why I do VEGF therapies in the first- and second-line settings. You mentioned that they’re tired, right? I get tremendous clinical benefit from EGFR as a single agent in the third-line setting.

John L. Marshall, MD: And it’s kind of a rest period for them, too.

Dale R. Shepard, MD, PhD, FACP: Yes. Their liver function could be abnormal. It doesn’t matter. They can have cytopenias. It doesn’t matter. It’s actually a nice rest period. Exactly like you said, it’s a little break, before you get to more rigorous therapies.

John L. Marshall, MD: Should I have them go see palliative care right now?

Michael A. Morse, MD: I thought that it was interesting that you brought that up. The term palliative is one that is…

John L. Marshall, MD: We call it supportive care.

Michael A. Morse, MD: Supportive care.

Johanna C. Bendell, MD: Symptom management.

Michael A. Morse, MD: Sadly, we still call it palliative care, and the conversation doesn’t go very far, unfortunately.

John L. Marshall, MD: But is this the right time?

Michael A. Morse, MD: Actually, they’re in our clinic. We work very closely with them. As people get used to the idea that symptom control is as important as the longer survival and the responses that people still want to try to get, it is important that they have this availability of specialists that can focus on that.

Cathy Eng, MD, FACP: Coping. Coping mechanisms. The ability to help their family, manage sleep disorders. It’s about keeping the entire patient healthy—outside of what we do with chemotherapy.

John L. Marshall, MD: That sort of “Don’t forget to live” message is important here too.

Cathy Eng, MD, FACP: Definitely.

John L. Marshall, MD: You’re still slogging. But the reason that you’re doing this is to keep going. I wonder if guidelines would help. We get a lot of pressure, as oncologists, from our intensive care unit teams and all of that. We don’t do a good enough job of communicating this because we’re kind of on the cheerleading side. They’re on the Debbie Downer side, if you will. Maybe we draw this up as “This is when the recommended palliative care referral is”? But it would make sense, even if they’re asymptomatic.

Michael A. Morse, MD: An emerging area that I think will make this discussion easier is the whole concept of patient-reported outcomes and allowing patients to have a closer link, versus the way our medical records work now. To be able to report some of those symptoms and have them acted on more rapidly. There was a recent presentation and, now, published data on longer survival for people who engage in patient-reported outcome interactions.

John L. Marshall, MD: It is fabulous data. So, we should give them their Mediport and a Fitbit, right?

Transcript Edited for Clarity 
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