Colorectal Cancer: Patient Follow-Up with Regorafenib
Insights From:John L. Marshall, MD, Georgetown University Hospital;Mohamed E. Salem, MD, Georgetown University Hospital;Monica Chacha, RN, BSN, OCN, Georgetown University Hospital
John L. Marshall, MD: So, we just decided with regorafenib (Stivarga) that we’re going to bring that patient back in 1 week. What are the key things you want to do at that visit, and then when are the subsequent visits?
Mohamed E. Salem, MD: First, you talk to them. You see how they feel, their performance status, their energy level. You want to make sure they’re not feeling worse than before you started.
John L. Marshall, MD: Do you check if they’re taking the drug?
Mohamed E. Salem, MD: Of course. Actually, I always ask them, “So, how many pills do you take?” They may say, “I take my pills.” I then say, “How many do you take and how many days?”, so you know they’ve got the right information. But also, blood work is needed, especially with regorafenib. You need to make sure the liver function is stable. One thing I learned from some of our colleagues here is that it’s nice, actually, to walk with the patient for a little bit and see how is he functioning. I learned that sometimes patients don’t like to tell you if they have symptoms because they’re afraid you’re going to stop the drug.
John L. Marshall, MD: Yes. We’re terrible at performance status, aren’t we? Because they come in dressed up for us. So, I do the same thing. I look at their hands. I ask open-ended questions like, “Did you have any trouble getting your drug? how many days have you taken so far?”, so I know what I’m assessing on that day 1. Because, sometimes, they haven’t gotten it and they’ve only been taking it for 3 days, maybe it’s too early to see some of the side effects. And then, depending on how they’re doing, I make adjustments or not. Key things on that first visit from a nursing side?
Monica Chacha, RN: So, some of the similar things, but I’m going to go in-depth and just see how they’re feeling on the medication. Are they having trouble eating? Are they having trouble with nausea? Are they having trouble with the hand-foot syndrome? Just more in-depth, side-effect type of things.
John L. Marshall, MD: And then, depending on how they’re doing at that visit, they’re back in a week or two.
Mohamed E. Salem, MD: Usually in the beginning, I like to bring them in the next week to just make sure everything is going okay. One other key element that patients also ask about is, “How is this related to food?” So, should they take it with food or should they not take it with food? And also, we want to make sure they have the antiemetic and supportive medications.
John L. Marshall, MD: And I don’t know if this is fair or not, but the package says “Take it after breakfast.” I tell them to take it after dinner, before bedtime, because if you’re going to be tired, you’re sleeping it off. But, they’re loosening some of that about when it can be taken after a little food, right?
Mohamed E. Salem, MD: Yes.
Monica Chacha, RN: Getting the full picture with patients is really important, so you can really know what’s going on. One way I do that is a lot of these patients I already have a relationship with, so they’re going to feel comfortable. Sometimes you can’t go right into, “How are you feeling on this medication?” You have to ask, “When’s your daughter’s graduation?” Start the conversation that way, and then go into it. Another thing that’s really helpful is sometimes the person sitting in the chair next to the patient is also a really good resource for you. Ask the family member how is she or he really doing? What are the things that they’re complaining about, on the daily basis, at home (not when they’re here in clinic with us)?
And then, another thing is for people to remember, I tell them to keep a pad at home. When they’re at home, they can write down, “Oh yeah, on this day, I was feeling so nauseous after I took the pill” or “On this day, I was having a lot of trouble with this.” Those kind of things are good tips. Because sometimes when the patient is there, they’re worried about maybe the news that they’re going to get from the scan or they’re thinking about what they have to do later that day. It becomes overwhelming in the clinic visit. If they have something like that, then they’re able to look back and refresh.