Panelists: Lee S. Schwartzberg, MD, University of Tennessee Health Science Center; Eric Roeland, MD, University of California, San Diego; Beth Eaby-Sandy, CRNP, OCN, University of Pennsylvania; Dawn Dolan, PharmD, BCOP, Moffitt Cancer Center; Howard Levine, PharmD, Queens Medical Associates
Lee S. Schwartzberg, MD: How do we use patient risk factors in our clinical considerations, Eric?
Eric Roeland, MD: In moving forward, we have these broad categories—especially with moderate emetogenic chemotherapy, where the range is from 30% to 90%. How do we stratify those patients within that group?
We’ve been talking about individual risk factors, and Dawn has mentioned some: young women, usually less than age 50, who have a history of motion sickness and low alcohol intake; this is one time where alcohol is helpful. And then, another risk factor is women who had a lot of nausea and vomiting with pregnancy. But by far, the most important risk factor, which is the highlight of our entire discussion, is that if you had CINV in your first cycle, you are 4 to 5 times more likely to have CINV in subsequent cycles. So, if you were to try to focus your attention on finding a time to call patients to see how things went, it’s after that first cycle.
Lee S. Schwartzberg, MD: That stresses the importance of optimal prophylaxis before cycle 1. We’re going to talk about the drugs. It’s so critical. We shouldn’t have to wait. Unfortunately, some payers use something called “step therapy,” which basically mandates that patients should get sick before they get the optimal regimen. I’m very much against that. I don’t think that’s an appropriate approach when we know so much about this field; we want to prevent it from day 1. And to your point about anticipatory CINV, in my experience, most of the anticipatory nausea comes after the patient has had the first bad episode, and then when they come into the clinic, they trigger. I’ve learned to not get too upset when the patient throws up at the site of me. I assume it’s just an effect from their chemotherapy.
How do you all use patient risk factors? How do you integrate them? We were talking earlier about putting together guidelines and pathways, and then giving our nurses the latitude to adjust those. How do you all do that in your practices with patient risk factors? Do you have a formal way of looking at them, at the beginning?
Beth Eaby-Sandy, CRNP, OCN: Absolutely, I can bring this back to my clinic yesterday. I started a 46-year-old female with lung cancer, yesterday, on pemetrexed, carboplatin, and an immunotherapy. She’s clearly anxious—she’s sitting there somewhat shaking in my office. So, this is a 46-year-old female patient with anxiety. She’s screaming for the best prophylactic antiemetic regimen I can give her. Even when carboplatin was considered as moderately emetogenic, I still would have given her every medication and hit every pathway of anti-nausea for this high-risk patient. It’s very easy to have a patient right in front of you, in which you want to look at those risk factors. You know right away.
Eric Roeland, MD: Beth, do you find that when you give the more aggressive prophylaxis at first, that then you can back off with subsequent cycles?
Beth Eaby-Sandy, CRNP, OCN: Absolutely. Again, backing off on subsequent cycles probably wouldn’t happen that often unless they were having some sort of toxicity from the actual antiemetic. But, boy, if something is working and somebody is feeling well, I rarely would back off. Probably, the steroids are the number-one thing I’d back off on, because that’s probably the most toxic of a triple-drug regimen.
Dawn Dolan, PharmD, BCOP: Always bringing it back to home, what if that was your family member or you? You would want the best drugs that we have possible to give to a patient. And I think one of the things that is, probably, most important to think about is our clinical experience. You get these young testicular patients—they don’t really hit a lot of the well-known risk factors. But, in my 15-years of experience, those guys tend to do pretty poorly, and they’re getting very big, heavy doses of chemotherapy. So, I think in those guys—even though they don’t hit the traditional risk factors—they tend to do worse than we would expect.
Lee S. Schwartzberg, MD: That’s a great point. I’m old enough to remember the era before 5-HT3s, and when I was a Fellow looking at patients in the Genitourinary clinic who were getting combination chemotherapy, it was brand new. With cisplatin for testicular cancer patients, a curative disease 30-years-ago—which was amazing—after 1 dose of cisplatin with no effective antiemetics, these young men came in and said, “I’m not taking any more chemotherapy.” And our job, as the Fellows, was to sit there and spend an hour convincing them to take cycle 2, 3, and 4. It was not an easy challenge at all. So, that’s a great point.