Transcription:
Palliative Care for Metastatic Cancer: Helping You Cope

Melanie Cole (Host): There’s more to cancer care than simply helping patients survive. There’s more to cancer treatment than simple survival. Constant pain should not be a part of conquering cancer. My guest today is Dr. Benjamin Cahan. He’s a radiation oncologist at City of Hope. Welcome to the show, Dr. Cahan. I would like to start by asking you, what is metastatic cancer?

Dr. Benjamin Cahan (Guest): Thank you for having me on your program. Metastatic cancer has to do with what happens when cancer spread beyond the initial site of disease. I think we all have a general understanding that cancer arises because of abnormal cells that arise in a normal organ of the body, things like breast cancer which arises in the breast, or prostate cancer which arises in the prostate. Unfortunately, in some circumstances, those abnormal cancer cells leave the organ that they arise from and can spread to other parts of the body. Once they have spread to other parts of this body, this is called “metastatic cancer”. Now, cancer can spread to a number of different sites in the body. We see it spread to lymph nodes; we see it spread to the bone; we see it spread to visceral organs. These all represent different disease states that generally require multiple types of therapeutic interventions to help patients in that setting.

Melanie: People hear the term “palliative care” and right away they think end of life care or hospice but there’s a big difference. Tell us about palliative care.

Dr. Cahan: I think that there is a very common misperception that when a patient is being discussed for palliative care that that means they’re out of options and we’re really just putting them on hospice and really that is far from the truth. In my mind, palliative care, are specifically your first medical interventions, are to help patients with symptoms. So, in the setting of metastatic cancer, for instance, when cancer spreads to other sites, it can cause specific problems. When cancer spreads to bone it can cause pain. When cancer spreads to the gastrointestinal tract, it can result in bleeding that can be difficult to control. So, when I’m speaking of palliative care, I’m really speaking of interventions that are trying to help patients who have those symptoms, patients who are having pain from cancer, patients who are having bleeding from cancer, or other such things. Our primary intervention, at least when it comes to radiation, is to try to make them feel better.

Melanie: Give us some tips for managing cancer pain and keeping it under control. Does the patient have to first quantify their pain? What do you do for them?

Dr. Cahan: That’s a very interesting question. I think we’re all taught vital signs when we go to medical school. I think these are commonly known things, like a patient’s temperature, and their heart rate, and their blood pressure. But, increasingly we’re referring to pain as the fifth vital sign, and you may have seen these scales when you go visit your physician, and we generally try to rank pain on a scale from 1 being “little to no pain at all” and 10 to being “excruciating pain”. So, I think all physicians, particularly in the setting up of metastatic cancer, like to get a good idea of the degree of discomfort that a patient as in. Once we’ve established that the patient is having pain and we understand that this is secondary to cancer, I think there are a lot of different things that we can provide for these patients. In the setting of metastatic disease, the primary backbone of therapy remains systemic treatments. By systemic treatments I mean drugs, for the most past, that try to fight off cancer everywhere in the body. These can be chemotherapy but, increasingly, there are novel agents that target specific mutations or can help the immune system fight off the cancer. However, these systemic therapies are usually not enough, and in the setting of pain, we often rely on radiation therapy which can provide highly focused and highly powerful x-rays that can try to treat the areas of the body that are in pain because of cancer. Of course, regular pain medications, opioid type pain medications, also play a role, and that’s why the understanding of the degree of pain that a patient is in is very important for managing these symptoms.

Melanie: Before we talk about radiation to help with these symptoms, when you mention opioids, people are a little bit afraid of addiction when they have to start taking pain medication on a regular basis. What do you tell them?

Dr. Cahan: I think this is a very common concern. In the popular press, we’re seen an explosion of stories about patients who have been having a very difficult time with chronic pain medications. For the most part, we counsel our patients that people who run into trouble with opioid pain medications are taking them for a very prolonged periods of time for, very often, questionable indications. For people have metastatic cancer, I think our goal is to have them off those pain medications in as short a period of time as possible. For instance, in the setting of cancer that spread to a bone that causes fractures or other discomfort, our hope is that we can start them on opioid pain medications and then shortly thereafter switch them, or decrease the dose of pain medications, or get them off them entirely, because other interventions specifically targeting the cancer can result in them feeling much better.

Melanie: What do you do as a radiation oncologist with radiation and these x-rays you mentioned to help with that pain management?

Dr. Cahan: Radiation therapy, for decades now, has been used for cancers in all sites of the body. What radiation does is it takes highly focused beams of x-ray radiation that cause DNA damage and results in, essentially, the death of the cancer cells. So, while we commonly use it for cancers that haven’t to other parts of the body as part of curative therapy, it remains a vital treatment for patients when the cancer has spread to other places. So, certainly, the most common thing we see is that cancer has spread to a bone somewhere and causes pain. This will generally result in a referral to a radiation oncologist who will see a patient in consultation. After consultation, we would begin radiation therapy. In general, there are two steps of radiation. Before you can deliver the radiation, you have to make sure that we’re targeting our beams of x-rays to the exact correct anatomic location. So, this requires the CT scan. It’s a scan that we call a CT simulation. A patient comes in, we have them lie in a particular position, we get a CT scan, and then we send them home. In the next couple of days, we need to do some calculations to design a radiation treatment plan that specifically targets the area that’s causing the patient’s symptoms. After a couple of days, they come back and begin radiation therapy. Radiation therapy for palliative purposes can be done in a very few number of treatments. Occasionally, we can treat patients in a single day of radiation therapy. Sometimes it requires daily treatment for up to 10 to 15 days. But, nonetheless, we try to keep the treatment as short as possible because, again, our primary intent is to make them feel better and improve their quality of life.

Melanie: Just to be clear, this is not helping to get rid of their cancer, this is strictly palliative, to help for that pain in their bones that has spread.

Dr. Cahan: Certainly, to get rid of the cancer everywhere in the body is not the intent of the radiation therapy. It really is focused on certain areas where they’re having pain. Now, we do eliminate some of the cancer cells in those areas, but we’re not targeting the cancer that can be everywhere else in the body, yes.

Melanie: Do people worry about the amount of radiation due to this type of therapy?

Dr. Cahan: Again that’s a common question that we get. There is always concern when we expose patients to ionized radiation and the primary concern is that we know that radiation exposure can contribute to a second cancer being caused sometime in the future. In general, the time period to get a second cancer from exposure to radiation—and by this I mean x-rays or radon when you fly in an airplane—can be quite a long period of time. It can take a 8, 10 years, or even longer to see a cancer formed and even those rates are extremely small. For us, we’re dealing with a patient with an acute need right now and our primary intent is to help them feel better in as short a period of time as possible.

Melanie: If it’s spread to the bones, is it hard to narrow down where it is? You mentioned the CAT scan, but what if it’s in many different areas? Then, do you radiate that many areas, or do you pick one spot where the pain is more severe than others?

Dr. Cahan: In general, when we see patients with cancer spread to multiple, multiple sites in the body, it’s difficult to provide radiation to essentially the total body. What we try to do is combine imaging, and by imaging that can mean CAT scans, but there’s other forms of imaging--PET scans and bone scans and other things--that can help us delineate where the cancer is. But, we also need to do a clinical and physical exam. We need to see a patient in an exam room and touch them and lay hands on them and try to figure out where exactly is the pain coming from and really limit our fields of radiation to target the areas that we think are causing the symptoms.

Melanie: Does this weaken the bones as a result, and is there an adjuvant therapy that goes along with that?

Dr. Cahan: It actually weakens the bone that is having cancer in the bone. So, we often think that the cancer you can think of like moths chewing up your clothes and these cancer cells are going into the bones and chewing it up actively. Now, bones try to heal themselves, but they are unable to heal themselves while the cancer is actively destroying the bone. So, in the process of eradicating the cancer in the local area, that allows the bone the opportunity to try to heal itself. We do know that radiation therapy can locally weaken the bone somewhat, but the doses we give in these palliative settings should not cause significant long-term harm. However, in general, we should continue to do good bone health, which requires visits with primary care physicians or medical oncologists and simple interventions like vitamin D and calcium are often recommended for all of our patients.

Melanie: Wrap it up for us, Dr. Cahan. It’s really amazing information on what you do. We applaud all the great work that you do. Wrap it up about palliative care for metastatic cancer and why they should come to City of Hope for their care.

Dr. Cahan: When it comes to cancer that’s spread outside the initial site of disease, when it comes to metastatic cancer, we are really in an area where we need all physicians on board. This is a true multidisciplinary effort. It requires radiation oncologists because we can provide a very local therapy, but it also requires world class medical oncologists who know the best systemic therapies that could help manage the patient’s disease. It requires social workers and therapist and psychosocial workers because there’s a lot of difficulties in family interactions that really all need to be brought together to provide the best type of care for our patients. Occasionally, our patients need surgery in the setting of metastatic cancer as well. So, one of the unique and special things about City of Hope is that we can bring world-class experts from all of these fields together to bring the full weight of all of our skills to try to provide the best possible care for our patients in these settings.

Melanie: Thank you so much for being with us today. You’re listening to City of Hope Radio. For more information you can go to www.CityofHope.org. That’s www.CityofHope.org. Thanks so much for listening.