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The Integrative Palliative Podcast
Conversations about communication, caregiving, and changing the experience of serious illness.
Hosted by physician, educator, and speaker Dr. Delia Chiaramonte, The Integrative Palliative Podcast explores one central question:
How do we improve the experience of serious illness when we cannot change the illness itself?
Through thoughtful conversations, practical tools, and evidence-informed insights, each episode helps listeners navigate the challenges of serious illness with greater clarity, compassion, and confidence. Topics include communication, family caregiving, clinician wellbeing, decision making, whole-person care, and the emotional realities that accompany serious illness.
Whether you're a healthcare professional, a family caregiver, or simply someone walking beside a loved one through illness, you'll discover practical skills that can improve your confidence, reduce your stress, and help you find meaning even if the patient's illness can't be cured.
If you're a caregiver, visit www.DoctorDelia.com for information about programs, resources, and personalized support from Dr. Delia.
If you are a healthcare organization or interested in discussing speaking or consulting with Dr. Delia, visit www.integrativepalliative.com.
The Integrative Palliative Podcast
Palliative Care Updates with Dr. Janet Abrahm
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Dr. Janet Abrahm is a Fellow of the American Academy of Physicians, Fellow of the American Academy of Hospice and Palliative Medicine, and a Fellow of the American Society of Clinical Oncology. She is a Professor of Medicine at Harvard Medical School, a former practicing oncologist, and an internationally recognized expert in supportive and palliative care for patients with cancer. She has over 20 years of experience in the forefront of palliative care at Dana-Farber Cancer Institute. She is the author of the newly updated Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer as well as an award-winning clinician and educator in palliative care.
This week she joins me to talk about the latest updates in palliative care. We chat about palliative precedes, the treatment of cancer related fatigue, new thinking about cancer cachexia and more.
You can learn more about Dr. Abrahm and her work at janetabrahm.com.
Here's to healing the heart of the healers,
Dr. Delia
Delia Chiaramonte, MD
www.integrativepalliative.com
Coping Courageously: A Heart-Centered Guide for Navigating a Loved One’s Illness Without Losing Yourself is available here: www.copingcourageously.com
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Welcome to the Integrative Palliative Podcast. If you care for the ill or aging, either at work or at home, this podcast is for you. You'll get plenty of tips for how to help care for the ill person and just as many tips on how to care for yourself. I'm glad you're here. Let's get started. Welcome to the Integrative Palliative Podcast. I'm Dr. Delia Caramanti, and I'm very excited about our guest today. Today we have Dr. Janet Abram. She is a fellow of the American Academy of Physicians, a fellow of the American Academy of Hospice and Palliative Medicine, fellow of the American Society of Clinical Oncology. She's a professor of medicine at Harvard Medical School, a former practicing oncologist, and an internationally recognized expert in supportive and palliative care for patients with cancer. She has over 20 years of experience in the forefront of palliative care at Dana Farber Cancer Institute. And she's the author of the newly updated Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, as well as an award-winning clinician and educator in palliative care. You can learn more about her at janetabram.com. And I am so excited to have her here to talk to us today to share her wisdom about new things in the palliative care world. Welcome, Dr. Abram.
SPEAKER_00Thank you so much. I'm really happy to be here and to share exciting new advances in some of our more troubling clinical challenges.
SPEAKER_01Yeah, so I'm hoping that we'll talk about things like management of pain, management of fatigue, cancer cachexia, and anything else that you think is important to share. So first off, if you wouldn't mind, just start by giving us an overview of how you feel like the field of palliative care is going.
SPEAKER_00Well, I'm really happy to report that I think it's thriving. I think many of us are calling ourselves supportive oncology now. Those of us in the oncology space, the Multinational Association for Supportive Care and Cancer has it in its name, basically. Love it. And so in Europe, in much of the world, what we do in the US in palliative care, what we call palliative care, is supportive oncology in the oncology space. Yeah. So we're being very welcomed into this space. ASCO guidelines suggest partnering with palliative care clinicians to help improve the quality of life and the treatment outcomes of patients with cancer. The only place that I see that we need more help, and that's why I did the website, again, which is free, completely free and available to anybody, is that more than half of our community oncologists don't have access to a palliative care clinician.
SPEAKER_03Wow.
SPEAKER_00And that really leaves them alone. And in some ways, I honestly think it promotes burnout and compassion fatigue if you don't have someone who can help you with the suffering of your patients because the drugs only go so far, as you know.
SPEAKER_02Right.
SPEAKER_00Their well-being can be enhanced so many ways by those of us in palliative and supportive oncology. And so the idea of the website, which we pretty much just launched, is to partner with those community oncologists to say, what are your issues? How can we help you in communication or symptom management or grief and bereavement? You know, all the key things that a community oncologist needs.
SPEAKER_01Yeah, I really love that. And it highlights something that I think people somehow forget, which is that just like in cardiology, for example, primary care doctors deal with cardiology issues. It's not that they can avoid cardiology issues, even though there are cardiologists. And in palliative care or supportive care, just because there exist people who specialize in palliative care or supportive care does not mean that regular oncologists and clinicians don't need skills to deal with the everyday things which they do. And often I feel like they're not sure what to do. And then as clinicians, when we don't know what to do, we feel badly and it makes our job less satisfying. And so I think what you're doing is really important.
SPEAKER_00Yeah. I feel that uh the best way to empower and to decrease burnout in oncologists, which I was for 20 years, is to partner with someone who can help you share that burden of uh situations that are tough and decisions that are tough.
SPEAKER_01Everybody needs some skills in managing communication with patients and symptom management, but then there are some specialized things that people like you have access to that your average oncologist may not be aware of. So, what are some of those things? Let's start with pain. What would you say are the newer things or the non-traditional things that regular oncologists might not know about to help their patients manage pain?
SPEAKER_00Well, I think that with more anesthesia interventional pain specialists around as they spread through the country, I think that the oncologists could take advantage of their skills. So if they could find an interventional pain specialist in their community to do localized therapies like trigger point injections or spinal blocks. But for the very difficult patients, intrathecal pumps, which for five or 10% of people can be life-saving because the pain is life killing.
SPEAKER_01Yeah.
SPEAKER_00The pain of very advanced pelvic cancers from any etiology can be life killing. Or the pain from a cancer that involves your chest wall can be, can ruin your quality of life. And if you get to know your anesthesia pain specialist, what they can do for you and your patients, I think that's very, very helpful. And it minimizes the drugs that people have to be on.
SPEAKER_01Yeah.
SPEAKER_00I think there's excellent data for acupuncture. So similarly, for people, especially aerobotase inhibitor-induced arthralgias, chemo-induced nausea and vomiting, there's lots of approved indications for partnering with acupuncture specialists. And we are lucky enough to have them available to us in Boston. There are there are plenty. So the idea is to find somebody you trust who understands about low platelet counts and bleeding and stuff like that. Yeah. Which most of the patients, that's not a problem for. And get to know what they can do to help your patients again to minimize the drugs that people have to use. Hypnosis, similarly, if you have hypnosis practitioners, I happen to be one trained. I don't teach hypnosis, but I was trained in hypnosis. It's a wonderful way to really have an intimate relation with your patient, with your voice, with your suggestions. Great for nausea and vomiting, great for pain, great for anxiety. Making tapes. Hypnosis can do all kinds of powerful things that drugs cannot. And it makes patients feel so much more empowered, even when it's a while for the drugs to work. Like my sickle cell patients used to say, Of course I'm in what you call trans doctor until the drugs work. How would of course I get away from it?
SPEAKER_03Yeah.
SPEAKER_00But I also had patients who said, even during chemo, that I helped them be somewhere they'd really rather be.
SPEAKER_01It gives people a sense of control that they can choose to be in a different place, which is such a gift when you feel so out of control.
SPEAKER_00I think that's exactly right. And so going a little bit, maybe even if you happen to have an interdisciplinary practice, if you have nurse practitioners or social workers, they can reach out to these practitioners in the community or you can invite them into your practice for a visit for coffee or something and see how you can all partner together for the most holistic, uh, most empowering, most gratifying ways to help. Pharmacologically, I think that methadone is an underused drug for cancer patients with nerve pain.
SPEAKER_01Talk to us about methadone, because I think conventional clinicians who don't use it sometimes have fears about methadone because they associate it with addiction, et cetera. So talk to us a little bit about methadone.
SPEAKER_00So I was lucky enough to use methadone before we had some of these other drugs, before we even had MS Cotton. It was my only long-acting agent. So I would use it as an oncologist as my long-acting agent, along with some oxycodone or some morphine or something. So I got pretty familiar with it. Now you're right, patients also worry. If you suggest methadone, you have to do an education thing. You know, I'm going to suggest something that you may have heard about that you may think I'm crazy to suggest. You need to do a kind of disclaimer. But for the oncologists, the same way that methadone clinics use 70 to 90 milligrams of methadone to stop the cravings. So most of the time these days we use buprenorphine instead. But methadone got that rep and it's still being used. What it isn't being used for as much as it could be is for people with neuropathic pain, especially involving the brachial plexus, the lumbosacroplexus, people who have that shooting pain down their leg or shooting pain down their arm or that burning pain. Now, regular opioids are not going to do much for this. And adding gabapentenoids adds more side effects. So that if you have a patient with heart failure, you're going to get edema with the gabapentenoids, or you may get too much somnolence. Now certainly they're they're great to use, lyrica, pregabolin, and gabapentin.
SPEAKER_01But they don't always work either.
SPEAKER_00And it's yet another drug that you have to take along with your opioid and your rescue drug, right? Right, right. So the thing about methadone, theoretically, is that it's a mixture of a drug that does two things. When you have nerve pain, people with that kind of nerve pain I just talked about have a different spinal cord from you and me, hopefully, in that they have chronic nerve injury. So their spinal cord tries to adjust to that. Central nervous system causes new amino acid receptors to be made that inhibit the ability of opioids to work. Literally.
SPEAKER_01I don't think I knew that. So that's that's fascinating. Wow isn't that interesting?
SPEAKER_00Yeah. And they're called NMDA receptors. You've heard of NMDA activators. For sure. Pure activators don't work for the they that's probably why ketamine works for pain. Is partly it's blocking the NMDA activity so the opioids can work. Right. So what's great about methadone is one half of it of the drug that you take is made to bind those. The other half binds the opiate receptors. So when you have nerve pain, you don't need much methadone because the other drugs are being blocked. You need a hundred milligrams of oxycontin three times a day, or MS cotton three times a day, 120, that kind of patient.
SPEAKER_02Right.
SPEAKER_00Who you're escalating, or 150 of fentanyl or something crazy where you're you're thinking, this is way too much, and they're still suffering, and they still got that shooting pain down their leg.
SPEAKER_01Yeah.
SPEAKER_00What the methadon does, we have ratios now of it. That's why it's good to, if you can, consult with either a clinical pharmacist or a palliative care specialist for the first conversion. You usually only need to start with methadone at five, three times a day, or 10, three times a day.
SPEAKER_01Yeah.
SPEAKER_00Usually that's plenty. Because 150 of oral morphine a day is the same as 15 of methadone.
SPEAKER_01Can you talk just briefly about the weird pharmacynamics of methadone?
SPEAKER_00Oh, yes.
SPEAKER_01Just so people know. Don't don't go out and start prescribing a whole bunch of methadone without learning first how to do it because there's a risk.
SPEAKER_00And I really do, I really think it's important to try to partner with somebody who's used methadone. Maybe it's your hospice provider.
SPEAKER_01Yeah.
SPEAKER_00Maybe it's your clinical pharmacist, as I said, maybe it's an oncologist, whoever. But you need somebody who who's like, oh yeah, methadone, what's the big deal? Right. You know. So the problem is it has a six-hour pain relief half-life, but it has a 24-hour biological half-life. Right. So that it takes three days to reach minimum, three to five days to reach steady state. So you can't stop your long actings day one, or your patient will hate methadone.
SPEAKER_01And also if they're completely pain-free on day two, you should be worried, right? Exactly. You're right.
SPEAKER_00Because by day five, they're asleep. They're going to be sound asleep. That's exactly right. And so, yes, I had that happen actually the other day. It's like, oh no. Oh gosh. Um, so instead, what we do is I usually look to see. Usually these patients have a lot of rescue opioid. So I leave the long acting and monitor the rescue opioid. As soon as, usually by day two, that goes down, then I can have the long acting. And by day three, usually you can stop it.
SPEAKER_01Yeah.
SPEAKER_00Now the patients we see as palliative care, it's not that simple, to be honest. But again, just to mention, I believe in the free chapter in the book, I do a method on conversion that's it that's in that chapter in the book.
SPEAKER_01Nice.
SPEAKER_00And I think it's free on my website. Oh, I should do that. I'm sorry. But they only let us put a couple of the chapters for free on the website. But I do a method on conversion for someone who is not in a crisis, who's at home. And I discuss this. And those also, it's like the old days when we gave people cumadin. You have to look at all the drugs that they're on. Yes. Or anything you think of starting, especially quintolones. Because our patients get community acquired pneumonias all the time, right? Right. Right. Yep. So stay away from quintolones. You will prolong the QTC like crazy with quinolones. You don't have to worry so much about the zoopran, the regland, those things, but you do have to worry about the potassium and the magnesium, because that prolongs the QT more than anything in our patients who are getting chemo and are wasting potassium and magnesium. Yeah. So get the calcium, magnesium, and potassium normalized. Stay away from quintolones and conozol. So when you have that patient with thrush, it's okay to use nystatin, but if you need a conozol, you're going to need to have the methadone dose.
SPEAKER_01Yeah.
SPEAKER_00Because they compete for the metabolism in the liver. Another reason to have a partner in crime here, you know, to say, what dose do you think? And again, we are lucky enough to have pharmacists rotate with us on clinical services.
SPEAKER_01Oh, nice.
SPEAKER_00So I have open access to what do I do about this? Because he just got started on Vorconazol. What do I what do I do about the methadone dose?
SPEAKER_01So I think the message here is don't be scared of methadone, even though it has all of these weird components. Use it, but do it alongside either a clinical pharmacist or a hospice and palliative care doctor or pain management doctor or something. So don't stay away because it's scary. Know how how helpful it can be in severe neuropathic pain, but maybe get a partner until you're comfortable using it, right?
SPEAKER_00Exactly. And if you have the this would be a great reason for a palliative care consult. That person will help you with the conversion and send the patient back to you when they're, you know, completely when they're on, when they're on a stable dose of methadone. Yeah, perfect. But it's really the patient who is just, you're thinking of admitting because they have such severe nerve pain, usually from plexus invasion. Usually that's what it's from, plexus or any of the plexi in the back, or retroperitoneal nodes. Retroperitoneal nodes that grab onto those nerve trunks can also give neuropathic pain.
SPEAKER_01And so what else? Presidex? What else? What else is out there that we can think about for pain?
SPEAKER_00So that's the everyday thing that I think will really make a huge difference. Now, what's presidex, you're thinking, all of you listening. She's not an anesthesiologist, she's not an ICU doctor. Why is she talking to us about Presidex? Why would we ever use that?
SPEAKER_03Yeah.
SPEAKER_00Well, luckily, one of our palliative care doctors is actually also an anesthesia doctor and an anesthesia pain doctor.
SPEAKER_01Nice.
SPEAKER_00And so she used to use Presidex in the ICU for patients who she didn't want much respiratory depression, but they had pain andor delirium. So it turns out that if you use Pressidex instead of some of the other sedating agents at a low dose, not an anesthetic dose, you really can help people with refractory pain andor delirium. And so what we got permission to use it in our unit, which is just an oncology ward designated with special nurses. So people can come out of the ICU on Presidex anywhere from 0.1 to 1.5 micrograms per kilogram per hour. And these are usually the people who have refractory pain from the neuropathic pain. And we've done the methadone. We've done ketamine even. And usually ketamine is just short acting to get them from dilatid to methadone. Usually that's what we use the ketamine for. They are at a stage in their disease where they are on comfort measures. That's required by the policy. And they want to be as awake as possible.
SPEAKER_01Right.
SPEAKER_00So we titrate the drug to, and we continue the pain relief and we continue the allanthopine or whatever they're on for their delirium. But these patients are refractory to those things. Usually it's a sarcoma patient or a GYN oncology patient who has just sucked in nerve damage down there. And even we've had people with intrathecal pumps who've who've needed it because the pain, either the cancer ate around the spinal cord, so the intratecal didn't work anymore, or um, it was at a different level. So this is the person who you're thinking about doing palliative sedation for symptoms.
SPEAKER_01Yeah.
SPEAKER_00But before you do that, if you can get, even if they have to be in an ICU and you start the Presidex, you will find that their pain and delirium reverse. We we published this a few years ago in the Journal of Palliative Medicine. We published our case series of eight, and there have been many publications since. Personally, I've had to do no palliative sedation for years with patients. And we have the worst you can imagine with Dana Farber being a sarcoma center. Right. You know, so we get 25-year-olds with horrible disease. That used to be the reason to do palliative sedation. And thank goodness, uh, we we've used Presidex instead of doing palliative sedation. Wow. Again, happy to share the paper with anybody who wants it.
SPEAKER_02Yeah.
SPEAKER_00Um, you know, if you write to me later on email, I'll send you the reference. But you can just, my name is spelled a little oddly, A-B-R-A-H-M. So if you search for that in Presidex, anybody who's watching, you will find the paper because there's nobody pretty much else who's a doctor named spelled who spells her name the way I do.
SPEAKER_01That's great. I I think that's such an important concept, too, that sometimes gets missed by people not in the supportive and palliative world, which is that if somebody wants alertness, no matter how close they are to death, that's a really important quality of life thing. And if we can manage their pain and give them some alertness, that that is a huge gift to them and to the family.
SPEAKER_00And control the delirium. You would be surprised how well it works with the delirium. And we anecdotally, we had a patient who was sent to us from the ICU and they thought they had to stop the presidex. So when we got her on our regular hospital ward, she was delirious and in pain. And we restarted the presidex at the same level, 0.7 mics per kilogram per hour. Delirium went away, pain went away, she was back to stable.
SPEAKER_01Why does is that because the the pain causes delirium, or is there some other mechanism by which it's addressing delirium?
SPEAKER_00It probably has to do with the alpha blockade business, but it the pain might be contributed to the delirium, but I honestly do not know the pathophys for that.
SPEAKER_01You mentioned ketamine also. I know people use ketamine for pain. Do you have a sense about ketamine for pain, ketamine for depression, which is another common usage? Do you have thoughts about that?
SPEAKER_00I don't have any data. I mean, I I have no special data on ketamine for depression. I would trust the psych data on that. We're not, we can't do that one-day infusion in the hospital, and I'm a hospital doc. So gotcha. That's a limitation of my knowledge. Ketamine for us tends to be the bridge between um an opioid that isn't helping a patient with neuropathic pain and methadone because often they're toxic on, usually it's hydromorphone, right? That they've just been getting boluses of that, 10 milligrams every two hours, something like that, along with 10 milligrams an hour and nothing's working. And they're starting to get neurotoxic. And the reason I'm saying it's short-lived for us is that they after two or three days, they go into that so-called K-hole. They start to get the psycho-imetic awful effects. The first two days, it's very unusual to have that as a problem. But you do have to pick people who don't mind it, who like hypnosis, for example, who want to be dissociated with you.
SPEAKER_01They dissociate, right? Yeah.
SPEAKER_00Now you don't take somebody who doesn't want to be dissociated or who's pre-delirious or who's right. You have to be very careful who you choose. And of course, we collaborate with our psych and our anesthesia pain colleagues on choosing the right person for ketamine. Yeah. But it is wonderful because to go to a family where somebody's myoclonic and neurotoxic and say, we actually have to stop the dilotic drug. You know, that doesn't go over very well.
SPEAKER_01Yeah.
SPEAKER_00Um, you know, because our colleagues on uh other units without consulting us have escalated things. Of course. You know, where you miss the ramp between delirium and and pain, and they missed they missed it, and now this person's really delirious and in terrible shape. Right. So usually I wouldn't give that person ketamine, but I definitely do give ketamine for two, three days. Usually by that time, there's enough methadone in the system that we can that the person's comfortable.
SPEAKER_01So it works. You feel like it works for a pain per se?
SPEAKER_00For us, it works. We haven't reported on it because other people had. Yeah. But it definitely works as the bridge. You just have to titrate it. You have to titrate it to their tolerability of the dissociation. But it definitely works to be able to decrease the dilated infusion. Some people use clonidine patches, you know, to prevent the withdrawal. But we since we have an opioid there, we don't feel like we have They're not withdrawing, right? They're not withdrawing. Yeah. But we're usually able to markedly decrease the PRN boluses that are making things worse.
SPEAKER_01I'm curious. I I've never taken ketamine. Do people hate the experience for the most part? Or are they fine?
SPEAKER_00I would say not. I would the younger the person is, just like with uh THC, the more they enjoy it. That's funny. Unless they have THC experience from the 60s, in which case they just remember that, oh, that's what that felt like. Got it. Okay. Just like with psychedelics, which I do not have experience in, but psychedelics for the way they're used, you have to put it into context. You have to prepare them that this is what it's going to be like. And we can always turn the dose down if you don't feel good. Right.
SPEAKER_01And you're safe and we're taking care of you.
SPEAKER_00You're safe. We're here. You're in a controlled environment.
SPEAKER_01So anything else that you think it's important that people are aware of for pain? Or shall we move on?
SPEAKER_00Well, BUSPAR patches, Butrans patches are really great for outpatients.
SPEAKER_01Ah, tell us more.
SPEAKER_00Um, they you can the highest dose you can go to is the equivalent of 80 of oral morphine equivalents. But there are many cancer patients who don't need more than 80, who are on, I don't know, 30 twice a day. The typical patient is on 30 twice a day for bone mats or for visceral mats or you know, just like that. Well, that patient can benefit from a buprenorphine patch because it's small, it doesn't have to be placed over fat, it lasts seven days. I don't know abuse potentially, you know, the fentanyl patches people used to put in the freezer and crack them and make them into what's called chiclets. Right. Because people would chew them. But those are the hospice patients I took care of too in West Philly. Their families would steal them, unfortunately, and make chiclets out of them.
SPEAKER_02Yeah.
SPEAKER_00I don't know if that can happen with the B perrofine patch, but they come in fives, tens, twenties. They're very, very useful, especially for your NPO patients who are hectic, because you can't use fentanyl patches for them.
SPEAKER_01And when do they get to steady state? Do they take a few days?
SPEAKER_00They take at least my the data says 24 to 48 hours. So that's what I would I would expect 24 to 48 hours. But if you have somebody who is in the hospital and you want to transition them, for example, to something, or or if they just don't want to take pills, they're tired of taking pills three times a day.
SPEAKER_02Right.
SPEAKER_00Um, I think it's a really great alternative. Our outpatient people are using it a lot. I found it very well tolerated.
SPEAKER_01And do you still use fentanyl patch or do you feel like you've transitioned?
SPEAKER_00Yeah, we do for higher doses, you know, because like 100 OMEs is a 50 fentanyl patch, you see. So if I need to go higher than the buprenorphine patch, the problem is in Europe they're available, but they prolong the QTC at higher doses than 20. So that's why they haven't been allowed in the US anecdotally. But fentanyl patches, a 50 fentanyl patch is is stronger than a 20 buprenorphine patch.
SPEAKER_02Yeah.
SPEAKER_00Because it's equivalent to 100 OMEs. So we definitely use those. They just have to be placed in the underarm. I cannot stress that enough. And not over tattoos. I last week I had a patient who had a full arm tattoo and it was on her tattoo, and we we fixed it, we put it under her arm the next day. She took no rescue. She said, This is so much better. Wow.
SPEAKER_01So the tattoo doesn't go through ink.
unknownAh, wow.
SPEAKER_00I don't that's really interesting. Or edema. So if you have an arm that looks great because it's lymphodematous, yeah.
SPEAKER_01But it's not, but you need fat. Fentanyl needs fat, which is so important. That's so right. It can't go through water to fat. It's so important though, I think, because I have seen multiple times people using it on very sick cacectic patients who have no fat and it doesn't work. And the other thing we have to be careful of, right, is if the person has a patch and they're cacectic, so it's not really working, but you think they've been getting that much opiate and now you transition them to morphine and now you're overdosing them because they weren't really getting as much as you thought they were getting, right?
SPEAKER_00That is exactly right. When I see a patient like that, we're called because it's not working. I don't take that into account. I just use the rescue doses, right? So to calculate what they need, I use rescue doses. But you know, in the old days, we probably still see this. I called it a fentanyl vest. They just kept putting more patches on their chest. Oh my god. So you're absolutely right. That's a big danger, is to is to assume that uh just don't take that fentanyl into account.
SPEAKER_01And so that issue of of needing fat is not an issue for the buprenorphine patch. Is that true? Correct. Correct. That's important.
SPEAKER_00Isn't that nice? So you start with fat if somebody doesn't want, but if but if you meet somebody, unfortunately, I re I sort of see people at at different stages than most oncologists care for. Sure. So my patients tend to need the fentanyl patches, but I would say most oncology patients would not need more than 80 OMEs, and there's absolutely every reason to use that patch. Very simple, lasts for seven days.
SPEAKER_01I know it was a while ago, but I I it's been on my mind to highlight one thing that you said, which is about acupuncture and aromatase inhibitors.
SPEAKER_00Yeah, that's ASCO's recommendation.
SPEAKER_01Right. So important because that is a way that acupuncture, in some ways, you could think of as life expanding. Because if someone is not willing to take them because they have this musculoskeletal pain, and some women just refuse, right? They'll say, I'm miserable, I'm just not taking this anymore. Send those people to acupuncture because if acupuncture makes them able to continue on the medication, then that may actually change their outcome.
SPEAKER_00That is 100% right. And I I would generalize that palliative care saves lives. I mean, I find it life-saving. When I was an oncologist, it was the only way I got 19 and 20 year olds through platinum chemotherapy was really knowing what to do about the entiometics.
SPEAKER_02Yeah.
SPEAKER_00And similarly, with my prostate cancer patients who were asking me to kill them from other doctors. We're talking about back in the 90s, you know, before pain was a fifth vital sign. That's what got me into palliative care was I had to know this stuff because I didn't want to kill these patients. They just needed opioids.
SPEAKER_02Yeah.
SPEAKER_00Oh, good for you to live. You know, so that is such a sort of how I morphed. I think I did oncology and palliative care for about 10 years as I learned more of these things.
SPEAKER_01That is really important. And I so appreciate that because, as you know, the the general feeling, even in medicine, I feel like is it palliative care and hospice care are basically the same thing. Like when you know your patients five seconds from death, you send them to palliative care, which is so not right. So thank you for saying that. You're right. If if you help people manage their symptoms and that allows them to continue with their life prolonging treatment, then maybe you prolong their life.
SPEAKER_00I really think so. And I think maybe this um change to calling ourselves supportive oncology. Yeah, like uh Edward Brero did a study showing that he got patients earlier when uh referrals when they called themselves supportive oncology. Yeah. So I'm perfectly happy with uh Dana Farber. I think we're going to be supportive oncology at Dana Farber and we'll be palliative medicine in our non-oncology manifestations like heart pal and kidney pal and taking care of people with neurologic disease or pulmonary disease will be palliative. But for I think our department has changed to calling itself supportive oncology, which is very interesting. It's fine with me.
SPEAKER_01Yeah. I mean, anything that gets people into the care that focuses on relieving their suffering, right?
SPEAKER_00Totally. Suffering is suffering and suffering, and our job is to help alleviate that.
SPEAKER_01Yeah. So what else do physicians need to know? What else do you think is important that they're they might be missing?
SPEAKER_00Well, the newest data on cachexia is pretty exciting. Tell us. Um, because there actually may be something if this phase two trial pans out as phase three, which is they've discovered this pro this protein called GLP15 that's high levels in like pancreatic cancer patients, lung cancer patients, the patients who have the cachexia that TPN doesn't help. And it may be the mediator of anorexia, cachexia, because they uh Pfizer or somebody produced an antibody. I don't want to be proprietary here. So an antibody was produced to that protein that's called Pensengramab. Okay. That's a mouthful. Um New England Journal uh has it online, the randomized trial, and it significantly improved the antibody, significantly improved appetite and weight gain for a change.
SPEAKER_01Really?
SPEAKER_00Yeah.
SPEAKER_01So where is this protein coming from? What is it? Is it a tumor-produced protein?
SPEAKER_00Yeah, it's tumor-producing. Just to quote them, if that's okay.
SPEAKER_01Please, yeah.
SPEAKER_00The inhibition of GD-15 with P O N S E G R O M A B resulted in increased weight gain and overall activity level and reduced caxia symptoms.
SPEAKER_01Wow.
SPEAKER_00Which they feel funded the role of GD15 as a driver of cachexia. And this was a large multi-center, 187 patients were randomized. And they were non-small cell lung, pancreatic, colorectal, the ones you'd expect to have this syndrome. And so this study was at 12 weeks. So that was a phase two study of three different doses. So I would keep my radar open for this one because if this pans out, it could be so helpful.
SPEAKER_01Yeah.
SPEAKER_00To these patients. Because nothing really otherwise works.
SPEAKER_01Did they feel better? I forget if you mentioned that thing. I know they had weight gain.
SPEAKER_00Their appetite was better and they had less cachexia symptoms.
SPEAKER_01Okay.
SPEAKER_00And physical activity, but I don't see a quality of life measure.
SPEAKER_01Physical activity is good though. I think functional activity.
SPEAKER_00And decreased cachexia symptoms is are really good.
SPEAKER_01Yeah. Wow, that's great. So that's not available now, of course, right?
SPEAKER_00No, this is phase two, but I just wanted to give you a heads up that this is the most exciting thing I've seen about cachexia.
SPEAKER_02Yeah.
SPEAKER_00Because, you know, mega puts fat on and makes you clot, so that's not great, though it improves appetite. Um, THC improves appetite in HIV patients and weight. Um, and if you don't mind getting high, you know, I what what I'm hoping is now that we can study T uh cannabinoids, just like there are a million opioid receptors, there's a ton of different cannabinoids. Right. And there's endocannabinoid receptors in the fourth ventricle of your brain where all the nausea stuff lives. Yeah. So I'm hoping they could target that, and then we'd get that other 25% of nausea that we haven't been able to um deal with with our multidrug combinations for chemoinduced nausea and vomiting. We got an unoccupied receptor in there.
SPEAKER_01Yeah.
SPEAKER_00Well, people use it for nausea and vomiting, right? Yes, it's good, right. And so I'm I'm sure that it's if they could isolate something, because people many people don't like the high feeling. And at the moment, they haven't figured out how to just isolate the fourth ventricle thing and not the cortical effects. Right now, unfortunately, you know, to get enough to block nausea, you have to be high. And people don't like that, many of them. Some people like it, some people like it. Some people don't like. Right.
unknownYeah.
SPEAKER_00But if you have that cachexia syndrome without much obstruction, then the TPN and the enteral feedings are not going to be helpful. So I think as a heuristic, if we have something that'll block that GLP 15, if that's the that's one of the agents that's really important, yeah, that'll be exciting because think of the procedures that won't happen.
unknownYeah.
SPEAKER_00In terms of somebody's quality of life and the side effects of all those enteric or parental feedings, yeah, that won't be needed. It'll just be wonderful.
SPEAKER_01That is wonderful. And even I think for the family, just the the lifestyle perspective of somebody who's hooked up to TPN versus someone who's just sitting in the living room the way they used to, it's very different, right?
SPEAKER_00You're absolutely right. And I I worry about that a lot. And I think that this is the most exciting thing I've seen. I really don't feel that anything else really addresses the Cachexia syndrome. Steroids, short-term appetite, of course.
SPEAKER_02Yeah.
SPEAKER_00Remron, mostly nausea at night, you know, or tazepine, but you have to give low doses, yeah, seven and a half milligrams, because the higher doses have no herpinephrine effects and stop the orectic, if you will, the positive of the anorectic. Stop the orectic effect, if you will, of Remron. So you can try that, you'll know in a couple of weeks if it works. It's more for nausea, really, than putting on weight. And they tried some other chemicals for lung cancer patients that were androgen related. And they put on lean muscle mass, but they didn't translate to any increase in strength or activity, unfortunately.
SPEAKER_01And so what about fatigue, which of course is a constant for cancer patients from the cancer, from the treatments, all of that. So what can you do?
SPEAKER_00Well, if you're a breast cancer patient getting adjuvant therapy, you should exercise. Yoga, aerobic exercise, my evidence is that both of those are NCCN recommends them. Everybody recommends them.
SPEAKER_01I would throw in Tai Chi, Qigong, meditative movement.
SPEAKER_00Yes, movement. And there's less good data that in other advanced cancers exercise helps. But if you can exercise, I think it's a good idea. And you certainly shouldn't think that resting will help you. Right. That's for sure true. It's the opposite, right? It's the opposite.
SPEAKER_01And for yoga, by the way, there are yoga therapists whose whole expertise is around modifying yoga for people who are ill in various ways. So seeing a yoga therapist might be a thing that you could do for help to make sure that you're not doing something dangerous or pushing yourself too much to make a yoga plan appropriate for your state of well-being.
SPEAKER_00Thank you for that. I agree completely. There's all the psychological and spiritual and existential inputs to fatigue. Yeah. All of those are real and important and have specialists that can help you. And pain, unrelieved pain is a huge impactor of fatigue and depression.
SPEAKER_01Yeah. Stress in general is just physiologically exhausting. And so doing all the things you just said to help reduce our sympathetic overdrive, reduce our stress can be a part of reducing fatigue. It's not going to be the only intervention that reduces all of your cancer fatigue, but if it improves you 15%, then that's 15% better that you feel.
SPEAKER_00I think that's important. Also, insomnia treatment. That's CBT for insomnia, which is the recommended treatment for insomnia, not drugs. Yep. CBT for insomnia, if you're well enough, a big reversible cause of daytime fatigue anyway, yeah, is getting your insomnia dealt with. And also check and see. I know this is kind of late to check, but if you are sleep apnea, because we are diagnosing more and more often in people who physically don't look like they might have sleep apnea.
SPEAKER_02Right.
SPEAKER_00So if you have insomnia, first you need your sleep apnea test. And then you definitely should do CBTI for insomnia, according to our insomnia experts at Dana Farber. That's my their recommendation.
SPEAKER_01I would also check your partner for sleep apnea who may be snoring like crazy and waking you up in the middle of the night where it's at a sub-level and you don't know it, but it's impairing your, yeah, I didn't think of that.
SPEAKER_00That's that's yes, you know, the environment. Unfortunately, there's a core nut of cancer fatigue, which is not sleeplessness, which is not anxiety, which is not stress. Yeah. Unfortunately, modafinil was clearly shown not to work. So it's important to know what not to take, right? As much as it is what to take.
SPEAKER_01Yeah. Do you have thoughts about Ritalin for fatigue, methylpenidate?
SPEAKER_00So yeah, there was one study by Eduardo and his group that if you have severe fatigue, that it improved at one point. What it does do, Ritalin, one we probably should mention that what Ritalin is really good for is the brain fog of opioids. This has been shown to be very clearly true. Huh. Is that if you have good pain relief, you're not like falling asleep all the time. It's just that your brain is not focused the way it used to be. It's foggy. Um, I think the people at Sloan Kettering, who dealt with a lot of actors and musicians, discovered that if they added a little bit of Ritalin, five milligrams, you know, for the four hours they were going to perform, yeah, it sharpened them right back up. Nice. I use it a lot and for patients who are intellectually uh their quality of life is very impaired by intellectual uh disability. It wouldn't be anybody else, but they know that they're not themselves. Yeah. It's the for me, it's like, who are you and who do you need to be and how can I help?
SPEAKER_01Right. I used it a lot too when I was in practice. Uh and what I wonder is when people say, quote, fatigue, I wonder what if that means the same thing to every person. It may not. It may be that I'm not myself. I'm not, you know, bright like I normally am. Maybe those are the people for whom Ritalin worked. Because what I found was it worked really well for some people and worked not at all for other people. That was my experience.
SPEAKER_00Well, I'm guessing that that's why. For people for whom, you know, doing the New York Times in Inc. on Sunday is there. Right. Then Riddlein's gonna help that a lot.
SPEAKER_01I have one funny story to share with you, which is I had one patient who had cancer who uh had came and said, such fatigue. And she was doing all the things. She had therapy and she was meditating and she was exercising, she was doing all the things, she had good support, but she said, I think I'm sleeping. I don't know why I'm so fatigued now. And in exploring, her partner mentioned that she was coughing. Because I said, Is anything impairing her sleep in the middle of the night? And she said, Well, no, not really, except her cough. I'm like, Cough, tell me about that. So it was reflux, and so I gave her a PPI and her fatigue completely improved. That that was only happened one time, but I was very well no, I mean by that experience and post-nasal drip, right?
SPEAKER_00No, that is a really cough is cough is a real sleep killer. I completely agree with that.
SPEAKER_01Yeah, but she didn't come in saying cough, she came in saying fatigue, right? So sometimes you have to dig a little bit.
SPEAKER_00Yeah, it's like people don't come in saying existential distress, they say pain.
unknownRight.
SPEAKER_00I mean, you sort of have to unpack um what their what they think their ticket is to the doctor in a way. Yeah, what's the thing that you'll pay attention to that you wouldn't otherwise pay attention to? Now that's not true for you. No, but there are some situations where the unless they say pain, they don't get attention.
SPEAKER_01As someone who has been in this world, immersed in this world for so long and has such a holistic approach, clearly. What would you say? What what is your advice to people who are not as schooled in this approach as you, but are taking care of very ill people? What's your advice to them?
SPEAKER_00Well, my advice to my fellow oncologists and hematologists is that you need a partner of some sort, not only for the symptom management, but to help with the grief. You really need to have someone who can share the care of the hardest patients with you and understand that it's medicine's failure, not your failure. Yeah. If it were your druthers, they would all go into remission and stay in remission.
SPEAKER_01That's right.
SPEAKER_00Because what we can do is help with that. We can normalize it, we can help with your third DNR talk of the day, as someone told me in that farewell you're talking about. I'm talking about clinician grief.
SPEAKER_01Yeah.
SPEAKER_00I feel like I had that. I didn't know what to do with it. I thought it was all my fault that anybody else could have taken better care of these patients than me. And it was only when I started to learn more about like suffering and to realize that my colleagues were suffering along with their patients. And the reason they sometimes didn't call us is because we reminded them of that suffering of the hardest patients. So if we worked with you more so that maybe we were just part of the team, it would be easier to partner with us. We really are there to help you. We know how hard this work is. Most of us are not oncologists, I happen to be one, but we know how hard it is what you take on every day. And to stay doing it, we would love to help you with the grief that that comes with it. That is beautiful.
SPEAKER_01Thank you so much for sharing that. Thank you. And and for normalizing it. It's not that grief comes when you're not handling it, it's just baked into the work for every single person.
SPEAKER_00It is baked in. And I learned that the hard way, like everybody does. But now we have in our in our service, we have a remembrance once a week for the people that have passed. So we get to talk about it. It comes out of the closet or we round on the empty bed. If you have a large office and you feel like you could do that once a month, wouldn't that be great if you felt like after that awful weekend on call, you could come in and it was normal to talk to somebody about it. My nursing colleagues have that. My nurse practitioner colleagues, social workers, of course, they have supervision. They never gave us any supervision or colleagues or anything. Right. Right. Like, what are we supposed to do with all this? So no one tells you what to do about it. Nobody tells you what to do about it. And so if if there's a way that you could build that in, I think it would be easier to come back to work Monday.
SPEAKER_01It is for me. Well, this has been so lovely and informative and heartfilling, actually. So if people want to learn more about you, remind them how they can find you.
SPEAKER_00Please just come to my website, Janet Abram, J-A-N-E-T-A-B-R-A-H-M.com. And you'll see me there. And we have resources for you. And if you sign up for my newsletter, which has just started, I'll be able to share more with you. And I would love suggestions for what to write in the newsletter. I think the one coming out this month is going to be about puzzling pain, because that seems to be something everybody wants to know about. But I don't know what you need to know. So please sign up for the newsletter. Please go to the website and let me know how I can be helpful.
SPEAKER_01Beautiful. And the the title of your book, one more time?
SPEAKER_00Oh, comprehensive, supportive, and palliative care for patients with cancer.
SPEAKER_01Fantastic. Thank you so much for your wisdom with us today.
SPEAKER_00Thank you for the hour. I've had a wonderful time talking with you, and I really feel uh grateful for this opportunity. Very grateful.
SPEAKER_01Me too. All right, everybody. Thank you so much for listening. You know, your homework is to go check out Dr. Abram's website. If it's pertinent to your practice, get that book. Because the last thing that she said that I think is so powerful is we all are in this together and don't feel like as someone who cares for seriously ill people that you have to do it on your own and you got to stuff your feelings about it. Let's all be in it together so we can support each other and help each other do this really important work. So thanks for being here, and I'll see you next week. Bye-bye. This podcast is brought to you by the Integrative Palliative Institute. Visit our website, integrative palliative.com. There you can access physician and clinician training, well being coaching, free downloads, and other cool stuff. And feel free to connect with me on LinkedIn and share your favorite episode with a friend.