Palliative Management for Patients with Gastroesophageal Cancers
Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Yelena Y. Janjigian, MD, Memorial Sloan Kettering Cancer Center; Manish Shah, MD, Weill Cornell Medical College; Ian Chau, MD, Royal Marsden Hospital
Johanna Bendell, MD: In the end, this is all about quality of life and making patients feel better and having them enjoy their time. And so much with gastric cancer, these patients are tough to treat. They have a lot of different things that can happen with them where they need specialized care for some of the symptoms that come along with their disease. Yelena, can you tell me a little bit, for instance, how do you approach nutrition in somebody who’s had a gastrectomy.
Yelena Janjigian, MD: It’s an adjustment period for the patient. From the day they’re diagnosed and they come in to see me, we start the discussion. I practice in New York and most of these people are hard workers who work 10-hour days and they’re used to eating just one big meal a day when they come home after work, and really slowly you have to change that practice. I recommend that my patients set an alarm clock and eat every two to three hours, small frequent meals, and really they retrain their biologic clock to get used to increasing their nutritional status, eating a well-balanced diet. And a lot of patients ask me whether they should stop eating sugar, or never eat meat again. And they have this perfectionist sort of self-punishing mentality that it’s their own fault that they got cancer. “I’m never eating a single cookie in my life and then I’ll be fine.” But, really, even though there is preclinical data that sugar may accelerate tumor growth in patients, there are no real data to support it. And, in fact, what I tell my patients is that the cancer will take from your body what it needs, and you really need to support a healthy lifestyle, balanced meals, and improved nutritional status. Because, particularly for post-gastrectomy patients, the data suggest that post total gastrectomy, folks can lose up to 20% of their body weight, and that’s what really limits our ability to get the therapy in adjuvantly, while we’re moving toward getting as much chemotherapy in the preoperative setting, and then really optimizing their quality of life and nutritional status in the postoperative setting.
Johanna Bendell, MD: And, speaking of sugar, so one of the things that happens with our patients is they get what we call, I don’t know if they call it the same in the UK, dumping syndrome, right, that you have a heavy sugar load.
Manish Shah, MD: Or carbohydrate.
Johanna Bendell, MD: Or carbohydrate load and you have a dumping syndrome. For the medical oncologist who’s having a patient who’s having these issues, how do you treat them?
Manish Shah, MD: It’s also a lot of education with what you can eat and what you can’t eat. I echo what Yelena was saying, that counseling patients with regard to modifying their lifestyle as much as possible is really helpful. I haven’t found a medication that actually helps dumping syndrome so much. It’s really modifying their diet and modifying their meals to a certain extent. But, I also explain that this actually evolves over time. So, there may be a period of time when they’re quite sensitive to carbohydrates and sugars, but over time it becomes less so, and they’re able to adjust and have some sweets and things like that. I also want to come back to the nutrition aspect.
We recently published a paper showing that malnutrition is associated with lower doses of chemotherapy and less survival which seems obvious, but there weren’t data before. So we’re now running a randomized study to see if intensive dietary involvement, could actually improve their nutrition and improve the doses that they receive. I think it’s a very important aspect. A lot of patients do have difficulty with that. And, of course, with regard to palliation, there are endoluminal stents that can sometimes be placed for patients who have obstruction in the distal part of the stomach or duodenum, that may provide some benefit, as well.
Johanna Bendell, MD: Yeah, these are the gastric outlet obstructions that you see. And I don’t know if any of you tried. I’ve had a couple of patients with really bad dumping syndrome and I’ve used octreotide which has helped, but, again, it’s a lot of testing and diet modification. And, certainly, with the nutritional aspect, things to think about with your patient with gastric cancer with anemia, certainly the stomach is used for absorption or easier absorption of certain vitamins. Yelena, you were alluding to some deficiencies that we should probably be watching for.
Yelena Janjigian, MD: Absolutely. It’s so important to stay on schedule with chemotherapy and anemia and low counts can really set you back. A lot of these patients come in anemic in the setting of occult bleeds. But, as you start the treatment, they stay anemic and that’s when it’s important to check for iron and B12 deficiencies due to poor absorption and malnutrition. These folks are very vulnerable for deficiencies in simple vitamins.
Johanna Bendell, MD: A very easy thing that’s real important to check. Ian, ascites, a big issue with patients with gastric cancer. Do you guys use diuretics? Do you find that they’re helpful? Do you use drainage catheters?
Ian Chau, MD: Yes, we do. I have to say, yes, we sometimes give spironolactone to patients, but usually we don’t find it very helpful at all for malignant ascites. So, therefore, we will put ascitic drains in. And our palliative care service actually has a more long-term indwelling catheter that our healthcare system allows for district nursing to go into their homes and actually relieve the drain once every couple of days for someone who’s obviously having very problematic ascites. Hopefully, if they’re still on treatment and the treatment can be effective and reduce that, but likewise, for a lot of people towards the end stage of their journey, that can be a real problem.
Johanna Bendell, MD: Manish was alluding to earlier and I think all of you have alluded to, is how important it is as a team to treat the gastric cancer patients. And it’s not just a doctor team, it’s a nutrition team. It’s a palliative care team. You’ve seen so much data that suggest that having a palliative care practitioner along with an oncologist will improve survival for patients who are going to surgery and physical therapy. All of those things are very essential parts of very specialized treatment of these patients. So searching for resources is a good thing.