Steven Grunberg, MD: The Importance of Supportive Care in Cancer

Dr. Steven Grunberg discusses the importance of supportive care in cancer at the ESMO 2012 Congress in Vienna.

Steven Grunberg, MD is a Professor of Medicine and Pharmacology at the Vermont Cancer Center.  He also serves as Treasurer of the Multinational Association of Supportive Care in Cancer.

The Group Room at the 2012 European Society for Medical Oncology (ESMO) Congress in Vienna was made possible, in part, by:

Daiichi-Sankyo  - EPS Full Color Lilly logo

VIDEO TRANSCRIPT

Selma Schimmel, Founder & CEO, Vital Options International

This is Selma Schimmel for The Group Room at the ESMO 2012 Congress happening now in Vienna, where we are now joined by Dr. Steven Grunberg, President of the Multinational Association of Supportive Care in Cancer, also known as MASCC.  Hello Dr. Grunberg.

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

It’s a pleasure to be here, thank you.

Selma Schimmel, Founder & CEO, Vital Options International

Would you define for us, what is supportive care?

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

Supportive care is a general term that has been used to mean many different things by many different people.  We consider it to be everything about the care of the cancer patient other than the actual administration of cytotoxic therapy, surgery, radiation.  It’s everything that surrounds that.  But we would say that good supportive care makes the rest of cancer care possible.

Selma Schimmel, Founder & CEO, Vital Options International

What are some of the greatest obstacles that you face in this whole area of supportive care both with patients, with providers, public perception, attitudes?

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

Like everyone else, we are limited by the resources that are available for the treatment of the cancer patient.  We certainly want to do as much as possible for our patients, but the question is, what does that actually mean?  Some of the obstacles we run into are people, and this could be patients or it could be providers, who might feel that this is somehow less important than killing the cancer itself, where in reality it’s all part of the same picture.  We also run into the perception, sometimes among patients and sometimes around doctors, that the side effects of cancer treatment are actually necessary for the efficacy of treatment.  And, that is totally untrue.  Vomiting after chemotherapy never made your chemotherapy work better.  But you will find that people, somewhere deep down, and, again, we’ve done surveys that looked at the obstacles to care, there are patients who believe that that’s exactly what the vomiting means, that their chemotherapy is working better and they would fear to lose that for fear that their chemotherapy would not be working.  Unfortunately we’ve also found that some providers believe the same thing.  We are trying to convince people or explain to them that we can separate these side effects from the treatment and still have the efficacy.  The modern form of that is actually with the new targeted therapies.  For example, the epidermal growth factor tyrosine kinase inhibitors, it is well known from the early trials that if you get a rash from these agents you are more likely to respond.  That has been assumed by many people to mean that you must get a rash to respond.  From the supportive care side we would say, what that means is that we have not learned how to control the rash yet and maintain the efficacy of the drug itself.

Selma Schimmel, Founder & CEO, Vital Options International

So, without proper supportive care, I think what happens is that the patient becomes entirely demoralized.

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

It’s that general term that we refer to as quality of life.  All of us know what it is; none of us could really define it.  But that’s what we’re talking about, it’s whether you feel that you can function and keep on your normal life.  Cancer, in English, is considered to be one of the three most frightening words in the English language.  And the one if you hear that you have cancer your whole world comes to a halt.  You do become separated from the world, separated from your friends, separated from everything and maintaining a normal life and maintaining a normal quality of life is certainly a worthwhile goal; not to replace curing the cancer, but rather, if possible, to be part of it.

Selma Schimmel, Founder & CEO, Vital Options International

Cancer patients also need to be very careful about their nutrition, it’s so hard to have decent nutrition if nothing tastes right and you have no appetite.

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

This has to be addressed on many different levels.  But first the question of nausea itself; we have made incredible progress in the control of chemotherapy-induced vomiting over the last 30 years.  You would usually hear it called control of chemotherapy-induced nausea and vomiting, but if you look closely at those studies, what we were really measuring was chemotherapy-induced vomiting.  Vomiting is at least 90 percent less than what it was 30 years ago.  But we are only now realizing that we were not really addressing nausea.  And that’s for many of the reasons you say, that nausea can mean so many different things to so many different people.  There are so many different terms in English, so many different terms in every language for what we might call nausea and it means something different to each individual.  It can certainly be debilitating.  One of major advances or ongoing advances is our realization that nausea is a different problem that may require different remedies.  We’re actually coming to realize that some of the drugs that we called antiemetics are very good at controlling vomiting, not very good at controlling nausea or there were other drugs that were put to the side because they were not very good at controlling vomiting but they may be very good at controlling nausea.

Selma Schimmel, Founder & CEO, Vital Options International

I’m curious for our viewers, can we talk about some of those drugs?  Because I bet some of them have been around a long time.

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

They have.  Corticosteroids are the simplest example which probably do more for nausea.  Megestrol acetate has been shown to have some effect against nausea.  Cannabinoids which are only moderate, very moderate drugs with significant toxicity if you try to go to the high doses to control vomiting, at very low doses may be good for controlling nausea.  And olanzapine is a new one that’s also being… that’s also being considered.  If you look at these drugs you will find that many of them were also used as appetite stimulants but if you think about it, what would the opposite of nausea be?  Probably having a good appetite.  So this is a whole new area that we are only now beginning to explore and which we hope will also benefit our patients because as you say, the continuing nausea may be an even bigger problem than the vomiting itself.

Selma Schimmel, Founder & CEO, Vital Options International

Do we even understand what is the basis of that ongoing nausea that can last, for some patients, ten days after treatment?

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

We know that the nausea is related to the vomiting because drugs that control vomiting do control nausea to a certain extent and vice versa.  So we understand the similarities, what we don’t understand is the differences.  And this is really new areas because some of the agents that I mentioned really do not affect the standard receptors that we think of as being those in the emetic pathway.   So we are really now looking for new pathways and different pathways so that we can more appropriately and specifically target those pathways to get more effective agents.

Selma Schimmel, Founder & CEO, Vital Options International

What do you want our viewers to understand about how they can best advocate for themselves in dealing with their physicians and trying to have discussions about their quality of life and their supportive care needs, because I imagine for each individual it can be different.

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

MASCC has sixteen different study groups, each of which concentrates on a different area of toxicity and, like with your children, I would be afraid to say that any one of them was my favorite.  They are all important, they are all very active, they all face different sorts of problems.   In terms of what our patients could say to their physicians I think they should simply say, is this toxicity really necessary?  Now, do I have to be going through this to receive effective treatment?  There may be times when…there may be times when it is.  At this point if you are going to get a very strong chemotherapy there will be, we can never say that there will be no side effects but to say, is this toxicity really necessary?  Is this degree of toxicity really necessary?  If you’re nauseous or vomiting you could ask your physician, am I getting the best antiemetics I could get or are there other options?  If the patient is having bowel problems, diarrhea or constipation, am I getting the most effective remedy for diarrhea or most effective remedy for constipation that I could be getting or could we change this?  You know, for example, for diarrhea most oncologists are used to using a drug such as Imodium, but they don’t realize that we can actually use doses much higher than one would use in standard care.  There are new remedies for constipation such as methylnaltrexone and other peripheral opioid-receptor antagonists that we don’t usually think of that can be highly effective and it’s not just constipation, it’s something that can be very painful and very disturbing to the patient that we can do more about than we used to.  So I think that simple question, is there more…is this toxicity actually necessary?… to start the oncologist thinking and looking into the literature and talking to people who have expertise in this field might actually go a very long way.         

Selma Schimmel, Founder & CEO, Vital Options International

Thank you, Dr. Steven Grunberg, President of the Multinational Association of Supportive Care in Cancer.

Steven Grunberg, MD, President, Multinational Association for Supportive Care in Cancer

My pleasure, thank you.

END OF VIDEO

Comments