Management of Chemotherapy-Induced Nausea and Vomiting (CINV) - Episode 6
Lee S. Schwartzberg, MD: Are any of you using the guideline-derived patient materials to help patients in the education of chemotherapy-induced nausea and vomiting? Dawn, have you used those at all?
Dawn Dolan, PharmD, BCOP: The NCCN patient guide is a fairly new document. I don’t have any personal experience, and I don’t have a lot of experience with patients using it, since it is so new. But, I have looked it over, and it’s a pretty extensive document. It has a lot of good information for patients and it’s easy to read.
Lee S. Schwartzberg, MD: There’s also a mobile app that has just been released. We talked earlier about calling patients, and I think in the future, as technology has been evolving so rapidly, we might have mobile solutions where we can interact with patients, and hopefully get some information right away without having to make that call. This can put, to some extent, the locus of control back into the patients’ hands, and allow them to communicate with us. I think that will be exciting going forward. Have you guys used any patient education materials that you particularly like?
Howard Levine, PharmD: We’ve come up with our own. Basically, we look at everything that’s provided from the various organizations and sort of filter down to a patient level what we think our patients can understand. And the basic point is to stress communication. We reach out to our patients a lot, and we’re able to because we have the staff to do it. But, that really is what helps guide us going forward. We’ll intervene at day 2, if necessary. We’ll say, “Listen, we’re going to get you some medication. We’re going to help you going forward for this cycle.” And then, we look at it again when they come back in. But, holding their hand is really important, and that’s kind of what we’re thinking about. We’re really holding their hands through this really important phase.
Eric Roeland, MD: Something I learned from my nursing colleagues—and I like how, Howard, you individualized that a bit more—is to really assess how people learn best. There is so much information thrown at us, especially in cycle 1, that people are just full of information; they can’t take any more. So, I like to stop and say, “Do you learn best with numbers or pictures? Do we need to talk this out?” And then, I like to revisit that. The repetition is the real key.
Howard Levine, PharmD: We’ve found, over time—and this is just counseling, in general—that you overwhelm people easily. We really summarize things down to 3 points, not 4; 4 gets lost, but 3 works. “If this, this, or this, happens, you need to call us. These are the 3 things that are really important about this specified treatment. Call us, we’ll be happy to talk to you. That’s what we’re here for.” And it tends to work. We do get calls, and those calls are specific. “You told me to call because of nausea, vomiting, or whatever, and that’s why I’m calling you.” And we say, “Great, we can help you with this.”
Lee S. Schwartzberg, MD: I think that’s a great point for our audience. Cancer treatment now, is so complicated. We’ve already talked about the fact that physicians are focused on the actual therapies and what the response is going to be, and then, you add on supportive care. There are so many things for patients to think about, and immediately, as soon as you start talking about cancer, 75% of what you talk about, they don’t hear. Although our tendency is we want to give them all the information, keeping it simple is a very important point so that they can respond to that, because there are so many pieces of this.
Howard Levine, PharmD: Yes, we give out information and it’s complete, but we highlight the things that are really, really important here. That’s kind of the way we like them to look at it.
Dawn Dolan, PharmD, BCOP: Repetition and reinforcement. And do you feel like, given your practice, that when you end up talking to patients, does that add an extra layer of confidence in the patient?
Howard Levine, PharmD: Absolutely.
Dawn Dolan, PharmD, BCOP: When a physician, or somebody from the healthcare team, reaches out to a patient, it adds that extra empathy. They say, “Yes, they’re really paying attention and they’re keeping track of what’s going on with me.”
Howard Levine, PharmD: You bet. It’s really important. Our patients like us for that. They say, “The pharmacy called me? Why? The pharmacy has never called me.” And our response is, “Well, we do.” It’s the practice that’s calling, and because of that, they feel like we’re paying more attention to them. And in fact, we are.
Eric Roeland, MD: As institutions start using more of these mobile technologies, we all need to stop and think about what we’re going to do with this information. So, if you have someone saying that their nausea and vomiting is out of control on day 2 or day 3, and that information is then coming to a nurse, then there needs to be protocols in place to clearly define what they’re supposed to do in that setting to really minimize the amount of communication back and forth between the doctor. That’s just something to think about as technology continues to grow.
Howard Levine, PharmD: We’ve kind of set algorithms. Whoever is making the call out, “If this, do this, if this, do that, if this, do this,” documents that the call is made. “Is everything good?” Check. “Not good?” They log down that the physician called, or the nurse practitioner called, or whoever it was.
Lee S. Schwartzberg, MD: We’ve done the same thing. We’re in an era, now, where many of us are participating in the Oncology Care Model and other types of alternative payment models. The locus comes back to us, and we have to control costs by reducing emergency room visits and by reducing hospitalizations. And CINV is a perfect area to work on, because if you have this communication and you have an algorithm, then you know how to deal with it. If you reach out to patients and they need hydration, they can come into the office as opposed to showing up in the emergency room, which, as we all know, usually means an automatic admit because they’re not used to dealing with cancer. They get cancer and they get nervous. “We better put you in the hospital.” That costs a lot of money for something that doesn’t need to happen if we have a focused way of taking care of the problem, and if we communicate with the patient. So, we get the information and then we deal with it, whether it’s done via a mobile app or through a telephone call. I think we’ll see more of that in the future, and I think that will be very good for the patients, and they’ll care.
Dawn Dolan, PharmD, BCOP: It will really also lend itself to better research and outcomes, because historically, nausea and vomiting is so hard to document because it’s under reported. Looking back, retrospectively, it’s really hard to get meaningful data out of that.
Lee S. Schwartzberg, MD: And nausea is subjective, so you can’t point to it. It’s not a lab test that we can point to and document.
Transcript Edited for Clarity