The Evolution of Sequencing Strategies in Pancreatic Cancer - Episode 7
Transcript:Johanna Bendell, MD: So, we talk about the multidisciplinary approach. John, you alluded to it earlier. These patients need a lot of support. They can be fairly symptomatic. Eileen, how do you guys work at Memorial Sloan Kettering Cancer Center? In your approach to this patient, what are some of the symptoms that you see and what kind of pearls do you have for the folks out there to help them?
Eileen O’Reilly, MD: We all know that this disease incurs a very high morbidity burden. And part of the challenge of maximizing the oncologic outcome is in making sure we take care of the patient and address their symptoms. So, optimizing nutrition, I think, is critical. Looking for any fixable problems, such as pancreatic insufficiency or exocrine insufficiency, is perhaps an unrecognized consideration for a lot of patients who walk in the door to see us. And it’s so gratifying to hear patients give us the feedback like, “Wow, I feel so much better when I eat.” And not having all of these digestive issues, for some, is very nice.
I think if somebody has nausea and vomiting, it’s more than just a cancer. You’re looking for another explanation, and the hidden one in this disease is duodenal obstruction. It’s not that common, but I think as patients are living longer and doing better, we are seeing it a little bit more. And because there are less people going to the operating room for exploratory surgeries and having a double bypass, that’s not so common these days. So, having your favorite interventional gastroenterologist help you manage that issue is important.
Then, a more common issue is cholangitis. It is important to make sure that complications with biliary stents are addressed. That, in itself, is a lot of morbidity for these patients. Pain management is critical. We use all the supports. For patients with newly diagnosed, untreated disease, I think our biggest tool is our therapies. If the therapies work, people will start to feel better. If the pain is relatively manageable, we’ll usually get by maintaining patient care within our team. But for those more complex settings, or certainly for people with progressive disease and pain challenges, I think having support from palliative care or even from anesthetic pain management. Caio brought up that nerve blocks can be done endoscopically or percutaneously. It’s a real art, I think, in terms of optimizing symptom control in this disease. It’s extremely important. So, we may need pain management, gastroenterology, or radiology colleagues to help us. Our surgery colleagues, on occasion, can help us to manage certain symptoms. It really is a team approach, and it’s not an isolated specialty in terms of taking care of the patient.
Johanna Bendell, MD: Do you have recommendations? For pancreatic insufficiency, we see this so often. Our patients come in with diarrhea. Sometimes they mention it, sometimes they don’t. It is associated with eating.
John Marshall, MD: Often the spouse mentions it.
Johanna Bendell, MD: It’s true, and sometimes you notice it in the exam room. I can’t tell you how many times I’ve had a patient come in to see me who’s taking one capsule and has said, “This doesn’t work.”
John Marshall, MD: Right.
Johanna Bendell, MD: So, what’s your thought and how far do you go?
Eileen O’Reilly, MD: You explain a lot and encourage people that these are substances we all make so it’s not uncommon. “You have to think of it as a natural substance.” You may suggest to have patients take the capsules right when they’re eating and explain that it’s a titration process. Explain that it’s not a perfect science and that we may start with 1 capsule and then go up to 2—if you’re taking more than 2, we’ll have you take half at the beginning and half halfway through (not an hour before, not an hour afterward). And we will see if we can get the balance right. But probably 60% of the patients, maybe even a little bit more, will have real tangible benefits from enzymes that are helpful, too.
John Marshall, MD: And right away. That night.
George Kim, MD: I agree with you. Absolutely, you’ve got to put the pills on the napkin while you’re eating, have the pill, eat some food, have a pill, and eat some food. I absolutely agree with you, and that’s the way it’s supposed to be done.
Johanna Bendell, MD: Caio, you mentioned gastroparesis. I think this is one of the toughest parts of pancreatic cancer. The patients get this chronic nausea and vomiting and they can’t get anything down. What’s your secret sauce for treating it?
Caio Max S. Rocha Lima, MD: Response—and that made the difference. I have treated patients with gemcitabine as a single agent, and that is a symptom that never went away. And the same with pancreatic insufficiency. It’s about the response of the pancreatic tumor and the pancreatic dilatation. Pancreatic insufficiency isn’t going away. The patients are burping, they experience early satiety, and they feel full easily.
So, now we have regimens that actually have the response rate. It’s quoted at one-third with FOLFIRINOX. It’s quoted as one-fourth with gemcitabine/nab-paclitaxel. But again, one is the center revealed and the other one is investigated. We may be calling upon similar response rates, but you don’t even need to have a RECIST criteria response if you have improvement in those medications. It doesn’t need to be a 20% reduction. The maximum diameter may just be in the right place at the right time and those symptoms will get better.
Now, when all this fails, we want to try to ask the patient to chew small bites, use more of their mouth, and do so more frequently. We also suggest not to eat and sit—eat and move around, and so forth, and eat more frequently. But I can attest that response makes a difference in this disease.
John Marshall, MD: One of the things that bugs me, still, is the therapeutic nihilism of the community—meaning a primary care doctor or a surgeon.
Caio Max S. Rocha Lima, MD: Absolutely.
John Marshall, MD: Or somebody who will say, “It’s not worth it, just go to hospice.” And “This is really effective palliative care, and oh, by the way, it extends survival.” So, I think that right from the beginning, when it is decided for a patient that this is a terrible disease and that nothing can be done, this is one of the barriers we have to moving the bar forward in this disease.
Caio Max S. Rocha Lima, MD: Can I quote a randomized trial that is probably one of the very first randomized trials that best explores supportive care in pancreatic cancers? This looked at old 5-FU (fluorouracil). The patient has a good performance status; had etoposide, which is not an active agent in this disease. They randomized patients through chemotherapy or through best supportive care, with the caveat that at progression, they couldn’t be treated with chemotherapy.
What we learned is that it cannot wait. If you wait to go to Disney World—or in our place, we go to the Caribbean—and come back, it’s too late. When the patients get ready to be restaged, their performance status has deteriorated so much that they could not even receive a drug. So, I think that trial was very important to me to discuss the issue about the importance of therapy and the importance of therapy now.
Johanna Bendell, MD: Yes. You make a very good point. The pancreatic cancer patients, as we all too well know, can get very sick very quickly without any warning. Trying to get that treatment going before that happens is incredibly important. John or George, do you have any other pearls that you use for pancreatic cancer patients to help them through?
George Kim, MD: I think the key is what was said earlier. You have to manage the patients. You have to be proactive. You have to address the pain, the nutritional issues, and the psychosocial issues. You’ve got to get on the diabetes. You’ve got to really manage that. It’s a tough patient to care for, but it’s very rewarding when things go well. And you’ve got to be careful with your opiates. Opiates can also cause gastroparesis or slowing of the gut. Some of our drugs can do that. Oxaliplatin probably does that, so you just have to pay a lot of attention. It’s not your typical patient visit.
John Marshall, MD: And until they get better, I like to see them often. For this kind of patient, it’s not about once-a-month visits. It’s maybe every other week or even more often, depending on how they’re doing, in order to fine-tune some of this.
And one other factor is medical marijuana. I take care of a bunch of 70-year-old hippies, not lawyers, who have gotten it on their own or whatever. And in the right patient, I’m interested. I was pushing back against this when it first came out. But the more that I see our patients using sort of pharmaceutical grade stuff, I am seeing that they do feel better.
Transcript Edited for Clarity