Research Highlights From the 2019 Supportive Care in Oncology Symposium, with William Dale, MD, PhD, and Joe Rotella, MD, MBA, HMDC, FAAHPM

October 21, 2019
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Today, we're going to be talking about some research highlights from the upcoming Supportive Care in Oncology Symposium.



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Greg Guthrie: Hi everyone, I'm Greg Guthrie, and I'm a member of the Cancer.Net content team. And I'll be your host for today's Cancer.Net podcast. As a reminder, Cancer.Net is the patient information website of ASCO, The American Society of Clinical Oncology. Today, we're going to be talking about some research highlights from the upcoming Supportive Care in Oncology Symposium. And my guests are Dr. William Dale and Dr. Joe Rotella. Dr. Dale is the Arthur M. Coppola Family Chair in Supportive Medicine at the City of Hope National Medical Center in Duarte, California. He is also the Cancer.Net Associate Editor for Geriatric Oncology. Thanks for joining us, William.

Dr. William Dale: Thanks for having me. I'm happy to be here.

Greg Guthrie: And Dr. Rotella is the Chief Medical Officer of the American Academy of Hospice and Palliative Medicine. Thank you for joining us as well, Joe.

Dr. Joe Rotella: It's nice to be here with you today.

Greg Guthrie: All right. Now, I also want to comment that William and Joe both served on the news planning team for this symposium, which means they helped select the studies that we'll be discussing on this podcast. So let's start off by discussing what is meant when we say “supportive care.”  William, what do you think when I say supportive care?

Dr. William Dale: So supportive care medicine, and we have a Department of Supportive Care Medicine here at City of Hope, focuses on providing quality of life considerations for patients in a multidisciplinary way to emphasize functional status, to emphasize overall health for patients. Within supportive care, almost any part of the multidisciplinary team could be included outside of the cancer-directed therapy itself. As an example, palliative care exists as a division within our department of supportive care along with psychology, psychiatry, interventional pain, social work and some others. So when someone says supportive care, I think of everything outside of the cancer-directed therapy that we might do on a multidisciplinary team.

Greg Guthrie: That's a great foundation to have before we jump into these studies. And the first one I'd like us to talk about is called “A pilot study of oncology massage to treat chemotherapy-induced peripheral neuropathy, also called CIPN.” So Joe, what is chemotherapy-induced peripheral neuropathy?

Dr. Joe Rotella: Well, peripheral neuropathy is a nerve damage which is often associated with neuropathic pain which can be of 2 sorts: sort of a constant burning or a deep kind of pain, or it can be more of a sharp and shooting type of pain. But it's associated with the toxicity of some common chemotherapy drugs, particularly those related to platinum and the Taxol family of drugs. And so it's a pretty common side effect of pretty common chemotherapy that's given to people with advanced cancers and not an easy symptom to treat. The typical pain medications that we would use for any sort of pain, for example opioids, don't always work that well for neuropathic pain. And, of course, there are safety issues and other concerns around using opioids. The other medicines that are often used might fall in the class of the medicines like Gabapentin, or anticonvulsants. And they also can have quite a few side effects and are just not terribly effective.

So this study looked at a nonpharmacological approach to managing the pain of chemotherapy-induced peripheral neuropathy. Very interesting, they looked at a standardized Swedish massage technique applied to the lower extremity, and then they had a number of other less intensive massage therapies that were used as a control. And they gave this 3 times a week over 6 weeks, and they were actually able to show a significant reduction in the symptoms related to the chemotherapy-induced peripheral neuropathy, and that it actually was sustained for up to 6 weeks after the massage treatment had been completed.

So this was fascinating that we could apply what appears to be a low-risk treatment that seems to be free of significant side effects that falls in that category of complementary alternative medicine that is so appealing to patients, and that this actually showed results that lasted beyond the duration of the intervention. And the less intensive control interventions did not result in as much symptom improvement. So very interesting study.

Greg Guthrie: Great. William, what do you think of this study?

Dr. William Dale: You know, peripheral neuropathy is extremely difficult for patients to deal with in our treatments as Joe just pointed out, are kind of notoriously ineffective. It works for a few patients, but often it doesn't that well and the side effects are quite high. So looking for alternatives to medications is something that's on all of our lists. Too often patients, in some ways, either get medicines or they're left on their own devices. We don't really have good evidence base to tell them what to do. Even though this study is not huge, it was very well constructed. So we know what kind of massage was used, what kind of evidence we had, and that it had a longer-term effect. And I agree with Joe that it's really nice to have an alternative that we can say has evidence that we might let patients consider and that's outlined in a way that lets us say this was a causal relationship or at least seems to be that patients were put into these two groups and it really was the group that got this very specific Swedish massage that had these enduring effects. So it'd be great to see this in a larger group of patients and to know for sure if this will work from a wider group of patients, but as a starting point, to have an alternative to medications for such difficult-to-treat side effect with such quality of life implications is really exciting.

The other thing I would mention and ask Joe about is they make the point that, these are licensed professionals. These were people who were expert at doing this kind of intervention. And patients sometimes ask, "Oh, can I get this?" And it would be nice to say just like any other intervention whether it was a medication intervention or a procedural intervention to say, "This is the way that this has to be done," and very specifically, what the outcome is expected. Too often we give vague information to people when it comes to so-called alternative therapies. But this was very specific to people trained to do this, presumably in patients who have cancer.

Dr. Joe Rotella: Yes, I agree. It's actually important to have a sense of what the intervention is that is actually performing better, let's say, than control or better than placebo or better than no intervention. The more we can pin down exactly what works and what frequency, what intensity is needed to get the optimal results, the more we can treat this like we would a pharmacological therapy where we can say, "Here's precisely what I recommend for you. Here's the dose. Here's the frequency. This is where the evidence says you're likely to get the most benefit." And I think there are certain interventions in complementary alternative medicine where we're starting to get there, where we can actually say, "This technique works better than that technique." And I think that's when we can begin to bring it into the same sort of rigor that we do our pharmacological treatments.

Greg Guthrie: Yeah, that's really great, just having an evidence-based approach to complementary therapies. So let's move on to our next study which is called “Anxiety, depression, pain, and social support in a large representative cancer population.” So what questions did this study set out to investigate?

Dr. Joe Rotella: This study started with the recognition that pain is a very common symptom in patients with cancer and actually looked at what are some associations with pain? How does it relate to the presence of anxiety and depression? How does it relate to whether people have good social supports or not? Can we start to get a sense of how these things all interrelate to modulate the intensity and frequency of pain? And this study was interesting because it really looked at over 11,000 patients. And it was looking at patient-reported information. These were patients who were undergoing treatment for anywhere from stage I to IV cancer who were using a tablet to record their symptoms and information in a large academic center. And through this large database, a lot of analysis could be done to determine what were the key drivers of pain or modulators of pain. And what they found was a number of things were independently associated with the severity of pain in these cancer patients, included the site of the tumor. For example, head and neck cancer versus gastrointestinal cancer. The degree or severity of the disease, how advanced it was. Race and ethnicity was a predictor, lower income, all of these were independently associated with severe pain.

But this study went a little further and looked at the effect of anxiety or depression and the level of reported social supports. And in all cases, if the patient reports high anxiety or high depression, it is associated with higher pain scores. But those could be further modulated by the degree of social support. So if a patient had low social support level as self reported, then the effect of the depression on pain was more. If they had anxiety and high levels of pain and the ones who had transportation issues, for example, tended to have even more pain. So with this really large database, we begin to get a sense of how these various factors interface. And it's not just a tumor type, it's not just a stage of the tumor, it's not just things like race, ethnicity, socio-economic status, but it's also the degree to which anxiety and depression are present and the degree to which there are social supports that can actually play a role in the level of pain that patients report. All of this would support this multidisciplinary holistic approach that we take in supportive care programs or when we're providing palliative care through a team. This really supports that concept that pain is not an island unto itself. The whole rest of the patients’ experience has a big impact on how they experience pain.

Greg Guthrie: William, what are some patient takeaways from this study?

Dr. William Dale: Yeah, to pick up on Joe's great summary of this, so overall, sometimes we have big studies but we don't have a reason for those studies to be big other than we happen to have a lot of data. What was nice in this study was they used the fact of a large dataset to show how the various variables interacted with each other. So in many cases, you can say well, if someone has a lower income or comes from a certain part of the world, whether a city or in an urban area versus a more rural area, they have worse outcomes. But, of course, those are very non-modifiable things. And it's perfectly fine to say it, but then what do we do about it? What made me feel good about this study was they said, "Well, if you have anxiety and depression, you can approach the problem this way. You can start to take care of those modifiable issues and that will help you with pain." Or if they live in a remote location, you could identify transportation. If you noted that they were living alone, for example, and they needed more help in the home, you could get that support. We all sort of feel that in our field, intuitively, that those things matter and are important. But this really started to connect the dots between pain and these other factors and how we might start to both take care of patients better, but to also start learning and putting the causal picture together about how this works.

And to your question about patient outcomes, so the idea of patient-reported outcomes has become more common and I think for good reason to actually ask the patient, “What's going on? What's their experience? How are they feeling?” And this was nice because it put an emphasis on that. And in many cases as they reported—this was on tablet computers—patients and respondents to surveys will be more honest when they're talking to a computer than they were to people, especially if it's their oncologist. We know that they will often become nervous, that if they could tell the oncologist, "Oh, I'm having these other problems," that someone might stop their therapy. And so they don't want that to happen when they really need those outcomes so they can identify what's needed. So screening people for these problems, which we advocate for, this just emphasizes how important they are even for something as basic as pain management.

And 1 other thing I wanted to mention, and Joe may want to weigh in on this as well, was this may help explain why we've had this so-called opioid crisis. And I don't want to overemphasize it, but if every time someone reports pain, our first instinct is to give them a medicine, especially an opioid medicine, and just increase the dose. Without identifying all these other factors, it's just an “If I have a hammer,” kind of solution to a problem, when really the multidisciplinary approach that palliative care and supportive care have always emphasized would do better even for something like the overuse of opioid medications.

Dr. Joe Rotella: William, I really agree with you on that. Actually, the founder of the modern hospice movement who really started the whole palliative care movement as well, Cicely Saunders, had a concept she called “total pain.” And what it meant was that you may experience pain physically, but it is an experience that involves your physical being, your mental being, your social relationships, your spiritual concerns, that the whole person plays a role in how you experience pain. And whether we're prescribing an opioid or massage or a ride to the chemotherapy center, whatever else we're doing, that multidisciplinary approach that looks at all the experience of the patient, not just their physical experience, but what's happening not just in their body, but in their mind, in their heart, in their spirit. That's really the key to giving people the very best quality of life. And those interventions that are less physically oriented tend to be lower risk, they're tolerated well. It's just a question of getting that team engaged and providing that more holistic approach.

Greg Guthrie: That's really great insight into this study. So let's switch to our third and last highlighted study for this symposium which is called “Racial/ethnic disparities in hospice utilization among Medicare beneficiaries dying from pancreatic cancer.” Before we delve deeper into the study, I think it's important if we define what hospice care is and what we may mean when we say disparities. So Joe, how would you describe these terms?

Dr. Joe Rotella: Sure. Hospice care is a particular form of comprehensive palliative care that's provided to people near the end of life. Palliative care, supportive care is appropriate at any stage of illness when patients may experience stress or symptoms. But hospice care is designed for those patients that are near the end of life. And in our country, we have a Medicare hospice benefit which is in myriad insurance benefits, which means that it's generally a care that is accessible to almost everyone who is designated as most likely to be near the end of life. The Medicare benefit actually requires a physician to predict that it's probably the last 6 months or so. And it's a very comprehensive form of palliative care. It's really the gold standard of care for people who are nearing the end of life. And so what's interesting about hospice care though is even though it's comprehensive palliative and supportive care with a team right where you live in your home, wherever you call home, a lot of people don't access it at all or they don't access it until very late. Nationally, the trends are that about half the patients with Medicare who die actually get any hospice care before they die. And of those who do get hospice care, half of them get it for less than 3 weeks. And so it's really not fully utilized. And we could do a whole separate podcast on why people don't fully use it.

But it's interesting then if it's sort of an underutilized service to try to determine either what drives that. And among other things, one way to try to understand it is to look at whether there are disparities. And by disparities, we mean, does 1 population seem to be treated or seem to be having outcomes that are different from another population who only differ, let's say, in race or ethnicity or gender? And so this study is trying to look at is there a difference in hospice utilization among Medicare beneficiaries who have a very specific condition? They're dying from pancreatic cancer. And again, large database looked at thousands of patients, and really, they were trying to see if there was an association between race or ethnic minority and the utilization of hospice before dying.

Pancreatic cancer is a high mortality illness, and in fact, in this study, something like 64% of the patients did die during the course of the study. And there was a difference. Those from ethnic and racial minorities were less likely to initiate hospice care before they died. What's also interesting though is that disappeared if you looked at the very short hospice stay. If you looked at the patients who only got hospice for 1 or 2 or 3 days before they died. In that case, you don't see a racial disparity. But for that earlier hospice care, you do.

This study can't explain why, but it really raises questions around why. Is it about how we present the option? Is it because there are different preferences for treatment near the end of life? Is it socioeconomic factors? Don't know from this, but what we can show here is just like with so many other parts of healthcare, there are in fact important disparities here that we should try to understand.

Greg Guthrie: William, what are your thoughts on this study?

Dr. William Dale: It's such a complicated story of why there are differences between groups. And this study has a great job of showing that we see these differences. I will reflect on my own personal experience of being in 2 different places with 2 different populations. First in Chicago where we had a mix of largely African-American patients and white patients, and now in Southern California where we have a group that's roughly one-third white, one-third Hispanic and one-third Asian. And just to take a simple thing like that, we all noticed differences in the communities with acceptance of the terms of hospice and end of life care. And I think we've all wondered gosh, it does seem like certain groups get it more often than others for a variety of reasons. And to have some data and a large dataset to show, that's really a good thing for us, so that we can advance to the next step of what are the reasons for that or as Joe just said, why is that? I note in the general population, about two-thirds of people when you ask them at the end of your life, what is your preferred location for dying? And two-thirds will say at home. And then when you look at the actual likelihood of where people die, it's about one-third that dies at home and about two-thirds that are in the hospital.

Dr. Joe Rotella: Just to add a little bit more, there was something interesting kind of a side observation, and that is that in this particular study, although there was that disparity, overall, 74% of the patients actually did receive hospice care before dying. And so that's actually much better than that 50% or so that you see across the board for all people with all serious illnesses. And another set of disparities we might want to look at sometime besides race and ethnicity would be disease-specific disparities. Why do cancer patients have a higher rate of hospice utilization than patients with end-stage kidney disease, for example?

Dr. William Dale: Yeah, that's a great point, Joe. And it makes me think of our ultimate goal when we talk about people having certain goals for their care including their end of life goals. And we use the term “goal-concordant care” so that people pass away where they want to. But boy, that is a moving target sometimes. And so it's helpful to just see well, where do we usually end up in terms of goal-concordant care. And cancer patients, I don't know what you think Joe, do tend to end up in hospice more often, but I still think the length of stay are pretty short even in the cancer population.

Dr. Joe Rotella: I think that's true. And a lot of times, I think it may have to do with when the patient stops taking chemotherapy or some other direct cancer treatment. And in many cases, that's close to the end of life, and so then the stay is short.

Dr. William Dale: Yeah, I think that's right. I do point out I'm at a cancer center. Our name is City of Hope. And so patients come here with that sense of their coming with hope for something. Usually some form of a new treatment or almost a miracle treatment that will rescue them. And we in the field are often trying to make sure patients understand hope for, can be hope for lots of different things. My old mentor, Bob Arnold, used to say hope for higher quality of life. Hope for meaningfulness. Hope for comfort. All should be part of the conversation. So broadening, again, beyond just the hyper focus on what can we do about this disease to a broader set of questions is probably the next thing we need to understand.

Dr. Joe Rotella: Yeah, that'd be a great podcast [laughter].

Greg Guthrie: Well, I wanted to say I've heard the terms quality of life, multidisciplinary, and overall health a lot in our discussion today. And I think that that really just underwrites the role that supportive care plays in cancer treatments. And I think that that's just a great way to summarize the really interesting research that's coming out of this year's Supportive Care in Oncology symposium. So William, Joe, thank you for coming onto this podcast to talk about these studies and to show how they can help start to make improvements in patients’ lives. I really appreciate you taking the time to join us.

Dr. William Dale: Well, thank you, Greg. We're looking forward to seeing these studies discussed at the conference.

Dr. Joe Rotella: It was a pleasure. Thanks so much.

Greg Guthrie: Thank you.

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