Providing Quality of Life during Survivorship

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:05provided by Smilow Cancer Hospital.
00:05 --> 00:07Welcome to Yale Cancer answers with
00:07 --> 00:09your host, Doctor Anees Chagpar.
00:09 --> 00:11Yale Cancer Answers features the
00:11 --> 00:13latest information on cancer
00:13 --> 00:14care by welcoming oncologists and
00:14 --> 00:16specialists who are on the forefront
00:16 --> 00:18of the battle to fight cancer.
00:18 --> 00:20This week, it's a conversation
00:20 --> 00:22about radiation oncology with
00:22 --> 00:23Doctor Vikram Jairam.
00:23 --> 00:25Dr Jairam is an assistant professor
00:25 --> 00:27of clinical therapeutic radiology
00:27 --> 00:29at the Yale School of Medicine,
00:29 --> 00:31where Doctor Chagpar is a professor
00:31 --> 00:32of surgical oncology.
00:33 --> 00:35Maybe we can start it off
00:35 --> 00:37by you telling us a little bit more
00:37 --> 00:38about yourself and what it is you do.
00:39 --> 00:41I have a somewhat generalist practice
00:41 --> 00:43treating a variety of diseases,
00:43 --> 00:48including genitourinary, CNS,
00:48 --> 00:49gastrointestinal, skin, lymphoma,
00:49 --> 00:52the occasional head and neck, and lung.
00:52 --> 00:54And I do see a fair number of
00:54 --> 00:56palliative patients as well.
00:59 --> 01:01And research wise or academically,
01:01 --> 01:04I do have an interest
01:04 --> 01:06in exploring
01:06 --> 01:08opioid use and opioid
01:08 --> 01:10prescribing in cancer survivors.
01:11 --> 01:14And just for our audience,
01:14 --> 01:15sometimes the terminology
01:15 --> 01:17gets kind of confusing.
01:17 --> 01:19Is therapeutic radiology the same
01:19 --> 01:20thing as radiation oncology?
01:21 --> 01:24Yeah, you know, more or less it is the same.
01:24 --> 01:27I'd say those terms tend
01:27 --> 01:30to be interchangeable with some departments
01:30 --> 01:32being called radiation oncology.
01:32 --> 01:34And our department you know historically
01:34 --> 01:36has been called therapeutic radiology
01:36 --> 01:39because we do actually treat a number
01:39 --> 01:41of benign or non cancerous conditions
01:41 --> 01:44as well, they comprise the
01:44 --> 01:45minority of our practice,
01:45 --> 01:48but we do treat some non cancerous
01:48 --> 01:50conditions with radiation.
01:51 --> 01:53One of the questions that
01:53 --> 01:55I have is you mentioned that
01:55 --> 01:56you finished your
01:56 --> 01:57training a couple of years ago.
01:57 --> 01:59That would have been right in
01:59 --> 02:00the thick of the pandemic.
02:00 --> 02:03So what was training like during the
02:03 --> 02:07pandemic and did that affect the care
02:07 --> 02:10of patients who were coming to see
02:10 --> 02:12a therapeutic radiologist for care?
02:13 --> 02:15Yeah, that's a great question.
02:15 --> 02:19You know, the pandemic occurred actually
02:19 --> 02:22during my last couple years of training
02:22 --> 02:26and I'd say it
02:26 --> 02:28changed things in many different ways.
02:28 --> 02:31We tried to figure out ways
02:31 --> 02:33that we could stagger our
02:33 --> 02:36presence in the department in order to
02:36 --> 02:38minimize exposure or contact.
02:38 --> 02:41We would kind of limit our
02:41 --> 02:43presence to mostly clinical days and on
02:43 --> 02:46non clinical days we would work from home.
02:46 --> 02:50So I guess from a interaction standpoint,
02:50 --> 02:52the interactions with
02:52 --> 02:54our colleagues and
02:54 --> 02:56with other people in the department
02:56 --> 02:59kind of decreased in frequency.
02:59 --> 03:01From a patient care standpoint,
03:01 --> 03:04we we did see a lot of
03:04 --> 03:08patients whose care ended up getting
03:08 --> 03:11delayed or who may have been lost to
03:11 --> 03:13follow up just because of the pandemic.
03:13 --> 03:14And you know,
03:14 --> 03:16there were some patients who did come
03:17 --> 03:18in with perhaps more advanced cancers
03:18 --> 03:21than we would have normally seen.
03:21 --> 03:24Maybe because they had missed screening,
03:25 --> 03:28imaging or other things that happened.
03:28 --> 03:30So I would say those are the main
03:30 --> 03:32ways that we would kind of see
03:32 --> 03:34differences and challenges that we had
03:34 --> 03:36to get through during the pandemic.
03:37 --> 03:39And did you find that
03:39 --> 03:42you know in terms of the
03:42 --> 03:44pandemic's impact on your practice,
03:44 --> 03:47did it change kind of the way
03:47 --> 03:49in which you delivered care?
03:49 --> 03:52So I know for example for us
03:52 --> 03:54in breast surgical oncology,
03:54 --> 03:56we started to think more
03:56 --> 03:58innovatively about well can we
03:58 --> 04:00use neoadjuvant endocrine therapy.
04:02 --> 04:04Can we think about ways of
04:04 --> 04:08getting people through their care
04:08 --> 04:11but keeping them out of the hospital as
04:11 --> 04:14much as possible. With radiation oncology,
04:14 --> 04:16did that play a role?
04:16 --> 04:18Did you start thinking about how
04:18 --> 04:20you could deliver the dose that you
04:20 --> 04:22needed to deliver perhaps in a shorter
04:22 --> 04:25period of time or using more of
04:25 --> 04:28those resources outside of the
04:28 --> 04:30main hospital where people might
04:30 --> 04:33have had less exposure to COVID?
04:33 --> 04:36Yes. So that's a great
04:36 --> 04:38question and that is exactly
04:38 --> 04:39what happened.
04:39 --> 04:42As a correlate to
04:42 --> 04:44some of the breast experience that
04:44 --> 04:46you had been mentioning,
04:46 --> 04:48just as an example,
04:48 --> 04:50some of our prostate patients
04:50 --> 04:52might have gotten started
04:52 --> 04:54on hormone therapy
04:54 --> 04:57for a period of time and then
04:57 --> 04:59they would come in a little bit
04:59 --> 05:02later probably to start their radiation.
05:02 --> 05:05And then in terms of the radiation
05:05 --> 05:06component itself,
05:06 --> 05:08there were many different publications
05:08 --> 05:09and there was kind of a push to seek
05:10 --> 05:13ways that we could
05:13 --> 05:15deliver radiation in fewer number
05:15 --> 05:18of fractions and perhaps
05:18 --> 05:21more single fraction or
05:21 --> 05:23minimal number of fractions for
05:23 --> 05:25patients who are being palliative
05:25 --> 05:28treated with bone metastases as an
05:28 --> 05:31example or ways that even in the
05:31 --> 05:33more definitive setting increasing
05:33 --> 05:36our utilization of techniques
05:36 --> 05:38like stereotactic body radiation
05:38 --> 05:41therapy or hypofractionated
05:41 --> 05:42radiation therapy,
05:42 --> 05:45which are both terms to indicate
05:45 --> 05:49a lower number of fractions and a
05:49 --> 05:53higher dose per fraction in order to
05:53 --> 05:55effectively treat the patient
05:55 --> 05:58and also increase convenience
05:58 --> 06:00and minimize the number of trips
06:00 --> 06:02and hospital exposure that these
06:02 --> 06:03patients have to come through.
06:05 --> 06:07And one of the things
06:07 --> 06:10that you mentioned is that you work
06:10 --> 06:13at a couple of locations that are
06:13 --> 06:15not at the main campus at Yale.
06:15 --> 06:18So you work more in a community kind of
06:18 --> 06:21setting for our listeners who
06:21 --> 06:24are listening to this, t
06:24 --> 06:27when is it OK to get your
06:27 --> 06:29radiation therapy closer to home
06:29 --> 06:32at a location that may
06:32 --> 06:34not be at a large academic center.
06:34 --> 06:37In in themiddle of a city,
06:37 --> 06:40but maybe on the outskirts or
06:40 --> 06:41in a community.
06:41 --> 06:43Is there a difference in the
06:43 --> 06:45radiation that you can receive in
06:45 --> 06:46the different settings?
06:46 --> 06:49And are there reasons why you might
06:49 --> 06:52want to be at the main center versus
06:52 --> 06:54at a peripheral center or vice versa?
06:55 --> 06:57Yeah. Also a great question.
06:57 --> 07:00I'd say the vast majority
07:00 --> 07:02of indications for radiation therapy,
07:02 --> 07:04can be delivered
07:04 --> 07:06effectively in a community setting.
07:06 --> 07:10And one of the benefits of
07:10 --> 07:13being part of a community practice that's
07:13 --> 07:16also connected to the main campus is that,
07:16 --> 07:19you know, I can determine and have a
07:19 --> 07:22discussion with the patient as to
07:22 --> 07:25if there are more nuanced or more complex
07:25 --> 07:28treatments that may require treatment.
07:28 --> 07:29In the main campus,
07:29 --> 07:31I can have that discussion with the patient.
07:31 --> 07:35But for the vast majority of indications,
07:35 --> 07:37patients can have care easily NOTE Confidence: 0.725791096
07:37 --> 07:39and effectively in the community.
07:39 --> 07:42And that's something that is truly
07:42 --> 07:45a joy to see because
07:45 --> 07:48for the vast majority of people,
07:48 --> 07:52radiation ends up being weeks
07:52 --> 07:55of their lives and the
07:55 --> 07:57convenience and
07:57 --> 07:58even finances
07:58 --> 08:01of having to come down to New
08:01 --> 08:03Haven or the main campus,
08:03 --> 08:06it can be sometimes difficult
08:06 --> 08:07or challenging for patients.
08:07 --> 08:11So I'd say the vast majority of
08:11 --> 08:14indications we can treat in the Community.
08:14 --> 08:16There may be certain more nuanced
08:16 --> 08:18or complex indications that we
08:18 --> 08:21can treat in the main campus,
08:21 --> 08:24but we have an active open line with
08:24 --> 08:26the main campus, which is phenomenal.
08:26 --> 08:28And so I can always get patients
08:29 --> 08:30in there if needed.
08:31 --> 08:33Great. So tell us a little bit
08:33 --> 08:35more about what drew you to
08:35 --> 08:37radiation oncology as a field.
08:37 --> 08:40I mean why, why do people get
08:40 --> 08:42drawn into radiation oncology?
08:42 --> 08:44It seems like it's quite
08:44 --> 08:46a niche kind of area.
08:47 --> 08:50So I'd say radiation oncology has a lot
08:50 --> 08:53of unique features associated with it.
08:53 --> 08:57One thing that I
08:57 --> 09:00really enjoyed was you really got the
09:00 --> 09:04opportunity to treat patients in a variety
09:04 --> 09:08of different disease sites from head to toe,
09:08 --> 09:09which is something you can
09:09 --> 09:11get in other fields as well,
09:11 --> 09:14but I really liked just the variation in
09:14 --> 09:17what you can do in radiation oncology.
09:17 --> 09:20So you have a lot of different
09:20 --> 09:22tools at your disposal.
09:22 --> 09:24You can treat patients with
09:24 --> 09:25external beam radiation.
09:25 --> 09:28You can treat patients with brachytherapy.
09:28 --> 09:30You can treat patients with a
09:30 --> 09:32combination of both. And there,
09:32 --> 09:35as we kind of alluded to earlier on,
09:35 --> 09:37there are various different
09:37 --> 09:38fractionation regimens.
09:38 --> 09:40You can treat patients,
09:40 --> 09:43you know conventionally fractionated or you
09:43 --> 09:46can treat patients with hypofractionated.
09:46 --> 09:50And I think the coolest thing for me
09:50 --> 09:54is that you can carve and shape the
09:54 --> 09:57radiation dose as best as you can.
09:57 --> 10:00And in order to avoid normal tissues
10:00 --> 10:04and you can kind of construct a really
10:04 --> 10:06neat radiation plan that maximizes
10:06 --> 10:09dose to the tumor and minimizes
10:09 --> 10:12dose to the surrounding tissues.
10:12 --> 10:15And I find the process of that treatment
10:15 --> 10:18planning just very fascinating.
10:18 --> 10:21As an aside, from a patient care standpoint,
10:21 --> 10:23you develop really,
10:23 --> 10:26really solid connections with your patients.
10:26 --> 10:29We tend to book
10:29 --> 10:31hour long consults in order to
10:32 --> 10:34discuss the nuances and different
10:34 --> 10:37aspects of radiation treatment planning.
10:37 --> 10:38And you know,
10:38 --> 10:41a lot of patients really enjoy the
10:41 --> 10:43amount of time they get to spend
10:43 --> 10:44with their radiation oncologist
10:44 --> 10:46and vice versa as well.
10:46 --> 10:49And you get to follow them for
10:49 --> 10:52long periods of time and establish really,
10:52 --> 10:54really great relationships.
10:54 --> 10:56So from a technical standpoint,
10:56 --> 10:58I think it's fascinating.
10:58 --> 11:00And then from a patient care standpoint,
11:00 --> 11:02it's really rewarding.
11:02 --> 11:05You know, one of the things
11:05 --> 11:07that you mentioned in terms of the
11:07 --> 11:09technical aspect is this idea of
11:09 --> 11:11targeting the dose to the tumor and
11:11 --> 11:13minimizing exposure to normal tissues.
11:13 --> 11:16And so that brings up the idea of it
11:16 --> 11:18sounds like that's really how you try to
11:18 --> 11:21minimize the side effects of radiation.
11:21 --> 11:23So can you talk a little bit more
11:23 --> 11:26about what side effects of radiation
11:26 --> 11:29therapy people might expect and how
11:29 --> 11:31prevalent those side effects are?
11:31 --> 11:35Yeah. So you know the side effects from
11:35 --> 11:37radiation therapy are varied
11:37 --> 11:39because it's a local treatment,
11:39 --> 11:41the side effects are very dependent on
11:41 --> 11:44where the patient is getting radiation.
11:44 --> 11:47I'd say the most
11:47 --> 11:49common thing that we see across all
11:49 --> 11:52disease sites is probably fatigue.
11:52 --> 11:53And you know, these side effects
11:53 --> 11:55tend to be cumulative during
11:55 --> 11:57the course of their radiation.
11:57 --> 11:59So patients during the
11:59 --> 12:02first couple of weeks may not notice
12:02 --> 12:03much, but you know,
12:03 --> 12:06towards the end of their radiation course,
12:06 --> 12:08that's when some of
12:08 --> 12:10these peak side effects may occur.
12:10 --> 12:13And you know, I'd say for some
12:13 --> 12:15patients they may peak
12:15 --> 12:18one to two weeks after radiation is done.
12:18 --> 12:21And that's something that I do like
12:21 --> 12:23to counsel patients about,
12:23 --> 12:26to expect that sometimes these side
12:26 --> 12:29effects may be kind of delayed
12:29 --> 12:32once their radiation is finished.
12:32 --> 12:34So you know, just to give an example,
12:35 --> 12:38I treat a lot of prostate cancer and
12:38 --> 12:41so you know the hallmark of side
12:41 --> 12:44effects from prostate tend to be,
12:44 --> 12:46you know genitourinary,
12:47 --> 12:50bowel side effects or rectal side
12:50 --> 12:53effects and sexual function as well.
12:54 --> 12:56I'd say it's it's one of those
12:56 --> 12:59things where a lot of it depends
12:59 --> 13:01on the surrounding organs at risk.
13:01 --> 13:03Or the tissues that are around
13:03 --> 13:04the area that you're treating.
13:06 --> 13:08So we're going to pick up the
13:08 --> 13:09conversation, talking about how
13:09 --> 13:10we manage those side effects,
13:10 --> 13:12maybe prevent them and certainly treat
13:12 --> 13:15them in terms of improving people's
13:15 --> 13:17quality of life as they go through
13:17 --> 13:19survivorship after radiation therapy,
13:19 --> 13:21right after we take a short
13:21 --> 13:22break for a medical minute.
13:22 --> 13:23Please stay tuned to learn
13:23 --> 13:24more with my guest,
13:24 --> 13:26Doctor Vikram Jairam.
13:26 --> 13:28Funding for Yale Cancer Answers
13:28 --> 13:30comes from Smilow Cancer Hospital,
13:30 --> 13:31where the gynecologic oncology program
13:31 --> 13:34brings together a team of clinicians
13:34 --> 13:36whose focus is to care for women
13:36 --> 13:38with gynecologic cancers.
13:38 --> 13:43Learn more at yalecancercenter.org.
13:43 --> 13:47It's estimated that over 240,000
13:47 --> 13:49men in the US will be diagnosed
13:49 --> 13:52with prostate cancer this year,
13:52 --> 13:54with over 3000 new cases being
13:54 --> 13:56identified here in Connecticut
13:56 --> 13:58one in eight American men will
13:58 --> 13:59develop prostate cancer in
13:59 --> 14:01the course of his lifetime.
14:01 --> 14:03Major advances in the detection and
14:03 --> 14:05treatment of prostate cancer have
14:05 --> 14:06dramatically decreased the number
14:06 --> 14:08of men who die from the disease.
14:08 --> 14:10Screening can be performed quickly
14:10 --> 14:12and easily in a physician's
14:12 --> 14:14office using two simple tests,
14:14 --> 14:16a physical exam, and a blood test.
14:16 --> 14:18Clinical trials are currently
14:18 --> 14:20underway at federally designated
14:20 --> 14:21Comprehensive cancer centers,
14:21 --> 14:23such as Yale Cancer Center
14:23 --> 14:25and Smilow Cancer Hospital,
14:25 --> 14:26where doctors are also
14:26 --> 14:28using the Artemis machine,
14:28 --> 14:29which enables targeted
14:29 --> 14:31biopsies to be performed.
14:31 --> 14:34More information is available
14:34 --> 14:35at yalecancercenter.org.
14:35 --> 14:37You're listening to Connecticut public radio.
14:38 --> 14:41Welcome back to Yale Cancer Answers.
14:41 --> 14:42This is doctor Anees Chagpar,
14:42 --> 14:44and I'm joined tonight by my guest,
14:44 --> 14:46Doctor Vikram Jairam.
14:46 --> 14:48We're talking about radiation
14:48 --> 14:50therapy for patients.
14:50 --> 14:52And right before the break, Vikram,
14:52 --> 14:54you were telling us about some of the
14:54 --> 14:55side effects of radiation therapy.
14:55 --> 14:58And one of the things that really drew
14:58 --> 15:01you to the field was the fact that you
15:01 --> 15:03can minimize those those side effects by,
15:03 --> 15:05you know, the technical aspects
15:05 --> 15:07of planning the radiation.
15:07 --> 15:10You mentioned that a lot of the side effects
15:10 --> 15:11tend to be local,
15:11 --> 15:13so in terms of prostate cancer
15:14 --> 15:16that there might be side effects for
15:16 --> 15:18bowel function,
15:18 --> 15:20sexual function, genitourinary
15:20 --> 15:22function, simply because of
15:22 --> 15:24the structures that are in that area,
15:24 --> 15:26regardless of how much you really
15:26 --> 15:29try to target the tumor itself.
15:29 --> 15:31So can you talk a little bit
15:31 --> 15:33more about that and
15:33 --> 15:35when people should expect those side effects,
15:35 --> 15:37what side effects they should expect,
15:37 --> 15:39and what do you do about that?
15:40 --> 15:42It seems to me that if the side effects
15:42 --> 15:45were really ubiquitous and really terrible,
15:45 --> 15:46the risk might
15:46 --> 15:48outweigh the benefit,
15:48 --> 15:50but it sounds to me that you have
15:50 --> 15:51ways of dealing with all of that.
15:51 --> 15:52Is that right?
15:55 --> 15:57One of the most important aspects of
15:57 --> 16:00managing side effects actually starts,
16:00 --> 16:03you know, before the patient actually
16:03 --> 16:05undergoes treatment and it's in
16:05 --> 16:07the treatment planning phase.
16:07 --> 16:10Much of that is in the
16:10 --> 16:12designing of the radiation plan.
16:12 --> 16:14When we design a
16:14 --> 16:16radiation plan, we're
16:16 --> 16:18looking at ways that we can maximize
16:18 --> 16:22dose to the prescription or target
16:22 --> 16:25volume that is designated by the
16:25 --> 16:27radiation oncologist and we're trying
16:27 --> 16:30to minimize ways or minimize radiation
16:30 --> 16:32dose to the surrounding tissues.
16:32 --> 16:36And we work with dosimetrists and
16:36 --> 16:39physicists in our department who are
16:39 --> 16:43trained and really expert at making
16:43 --> 16:46these radiation plans in order to
16:46 --> 16:50achieve the goals that we set forth.
16:50 --> 16:52You know some of the radiation
16:52 --> 16:55dose that goes to normal tissues,
16:55 --> 16:58that's been studied and
16:58 --> 17:00validated in multiple clinical
17:00 --> 17:03studies as to what dose correlates
17:03 --> 17:04with what side effects.
17:04 --> 17:07And you know based on these studies
17:07 --> 17:10we have certain thresholds that we try
17:10 --> 17:14not to exceed during our radiation planning.
17:14 --> 17:17And so with the help of our dosimetrist
17:17 --> 17:20and physicists, we can usually
17:20 --> 17:22achieve a radiation plan that's
17:22 --> 17:25acceptable and that really
17:25 --> 17:27achieves the overall goal of what
17:27 --> 17:27we're trying to do.
17:30 --> 17:32And so despite your best efforts,
17:32 --> 17:34my presumption is that some people
17:34 --> 17:36still get side effects. Is that right?
17:36 --> 17:39Absolutely. And you know side effects
17:39 --> 17:41are to be expected and you know this
17:41 --> 17:44is part of the conversation that we
17:44 --> 17:46have during our patients or during
17:46 --> 17:48our consults with patients that you
17:48 --> 17:50know side effects are to be expected.
17:50 --> 17:53And you know we try and manage that
17:53 --> 17:56depending on the severity
17:56 --> 17:59of side effects and much of that
17:59 --> 18:01is very patient dependent.
18:01 --> 18:04So let's take prostate for example.
18:04 --> 18:07Much of a patient's baseline
18:07 --> 18:09urinary function or bowel function
18:09 --> 18:12or sexual function may determine the
18:12 --> 18:15severity of side effects that they
18:15 --> 18:17received during radiation therapy.
18:17 --> 18:22And so being able to manage expectations
18:22 --> 18:25as well as manage the side effects
18:25 --> 18:27is really important in order to
18:27 --> 18:29get patients through
18:29 --> 18:31their course of radiation.
18:31 --> 18:33What kinds of things would you
18:33 --> 18:35suggest for patients who have
18:35 --> 18:37either local side effects,
18:37 --> 18:39like you mentioned, or fatigue,
18:39 --> 18:40which was another side
18:40 --> 18:41effect that you mentioned,
18:41 --> 18:43was nearly ubiquitous among
18:43 --> 18:46patients who have radiation therapy
18:46 --> 18:47during treatment.
18:47 --> 18:49Patients meet with their radiation
18:49 --> 18:52oncologist once a week just as a check in.
18:52 --> 18:54We call them on treatment visits.
18:54 --> 18:56And you know, I definitely
18:56 --> 18:58encourage patients to discuss any
18:58 --> 19:00side effects that they experience
19:00 --> 19:03with their physician during
19:03 --> 19:05these on treatment visits.
19:05 --> 19:06So as an example,
19:06 --> 19:09you know one of the most common side
19:09 --> 19:11effects that I tend to hear is,
19:11 --> 19:15you know urinary frequency or
19:15 --> 19:17irritable urination symptoms.
19:18 --> 19:20That's important for me to hear
19:20 --> 19:22because that is something that
19:22 --> 19:23is manageable with medication,
19:23 --> 19:26a variety of different medications.
19:26 --> 19:29From a more systemic standpoint.
19:29 --> 19:31I know you also mentioned fatigue.
19:31 --> 19:34Fatigue can be challenging.
19:34 --> 19:35I'm not going to lie.
19:35 --> 19:38And, you know, during radiation,
19:38 --> 19:41what I say is to try and
19:42 --> 19:45not overexert oneself to listen
19:45 --> 19:47to your body as much as possible
19:47 --> 19:50because fatigue is cumulative.
19:50 --> 19:53And I don't like
19:53 --> 19:56having people kind of overexert
19:56 --> 19:58themselves during treatment.
19:58 --> 20:00Once radiation is completed,
20:02 --> 20:04I think there is good data that
20:04 --> 20:06shows that exercise can help
20:07 --> 20:09overcome fatigue and especially
20:09 --> 20:12in prostate patients who may be
20:12 --> 20:13getting hormone therapy as well,
20:13 --> 20:18which may also add to the fatigue,
20:18 --> 20:20exercise is something that has
20:20 --> 20:23been shown to actually increase
20:23 --> 20:26the metabolic rate and improve
20:26 --> 20:28overall general function
20:28 --> 20:29for a lot of patients.
20:29 --> 20:32So it is something that I discuss with them,
20:32 --> 20:34but you know we kind of save
20:34 --> 20:35that till after they're finished
20:35 --> 20:37with their radiation.
20:37 --> 20:39Now one thing that you mentioned at
20:39 --> 20:42the top of the show was that your
20:42 --> 20:45research interests really revolve at
20:45 --> 20:48least in part around the use of opioids.
20:48 --> 20:50We didn't really mention too much
20:50 --> 20:51about radiation induced pain.
20:51 --> 20:54Can you talk about pain as a factor
20:54 --> 20:57that happens after radiation therapy?
20:57 --> 20:58How frequently
20:58 --> 21:00that happens and how often you
21:00 --> 21:02need to use opioids
21:02 --> 21:03in that setting?
21:03 --> 21:05I'd say radiation induced pain
21:05 --> 21:08is something that can happen.
21:08 --> 21:10It's not a common side effect, but it
21:10 --> 21:12really depends on what you're treating.
21:12 --> 21:16So you know, if you're treating an area
21:16 --> 21:20where there's bone or rib or chest wall,
21:20 --> 21:22you know, generally with
21:22 --> 21:24conventionally fractionated radiation,
21:24 --> 21:27rib pain is not a common side effect,
21:27 --> 21:29however, when you're going to
21:29 --> 21:33higher doses or more stereotactic body
21:33 --> 21:36radiation, rib pain is something that
21:36 --> 21:38can happen. If there is chest wall,
21:38 --> 21:42for example, if you're treating a lung cancer
21:42 --> 21:45and there's chest wall around that area,
21:45 --> 21:48or if you're treating cancer that has spread
21:48 --> 21:52to the bone and you're actually treating
21:52 --> 21:55that bone itself with palliative radiation.
21:55 --> 21:58Sometimes patients can experience what
21:58 --> 22:02we call an inflammatory reaction.
22:02 --> 22:04And you know
22:04 --> 22:06most of these inflammatory reactions
22:06 --> 22:09when patients have rib pain or you
22:09 --> 22:10know bone pain from radiation,
22:10 --> 22:13they tend to be self limiting.
22:13 --> 22:16And so you know because of that nature we
22:16 --> 22:19do talk about treatment conservatively with
22:19 --> 22:23over the counter pain medications first,
22:23 --> 22:24sometimes more topical,
22:24 --> 22:27you know lidocaine patches or
22:27 --> 22:30creams and if you know these pain,
22:30 --> 22:31if this pain kind of persists
22:31 --> 22:33over a longer period of time then
22:33 --> 22:36you know there's a discussion about
22:36 --> 22:38opioids or narcotics for management.
22:39 --> 22:41And so it sounds like opioids are really
22:41 --> 22:44kind of the the last resort is that right?
22:45 --> 22:48So I would say
22:48 --> 22:51if we've exhausted all other
22:51 --> 22:54measures then certainly, however,
22:54 --> 22:57if a patient is having pretty
22:57 --> 22:59excruciating pain for whatever reason,
22:59 --> 23:02if it's from the cancer itself
23:02 --> 23:05or from another cause you know the
23:05 --> 23:08NCCN does mention that for moderate
23:08 --> 23:11to severe pain that's on a scale
23:11 --> 23:14that's a four out of 10 at least,
23:14 --> 23:17opioids are the mainstay of treatment.
23:17 --> 23:19So you know while I would start with
23:19 --> 23:21conservative over the counter measures,
23:21 --> 23:24I would have a lower threshold for
23:24 --> 23:27starting patients on opioids if they are
23:27 --> 23:30experiencing more moderate to severe pain.
23:31 --> 23:34Let's ask you about
23:34 --> 23:36concern over getting addicted to opioids,
23:36 --> 23:39especially given all of the
23:39 --> 23:41hype about the opioid epidemic.
23:42 --> 23:45So that's one more common
23:45 --> 23:47concern that patients bring up,
23:47 --> 23:49either you know patients
23:49 --> 23:52may not like the feeling of being
23:52 --> 23:55on an opioid which is one thing and
23:55 --> 23:58certainly very fair or just the
23:58 --> 24:00concerns about being addicted
24:00 --> 24:02because you know many patients are
24:02 --> 24:04opioid naive and have never taken
24:04 --> 24:06pain medications that are this strong.
24:06 --> 24:11And our group has
24:11 --> 24:13actually published data and has looked into
24:13 --> 24:17this and we've found that while
24:17 --> 24:20most patients with cancer may actually
24:20 --> 24:24use or be prescribed higher doses of
24:24 --> 24:27opioids compared to non cancer patients,
24:27 --> 24:30the rates of misuse or addiction
24:30 --> 24:34are actually fairly low and not too
24:34 --> 24:37dissimilar from the general population.
24:37 --> 24:40And so I do try and reassure patients
24:40 --> 24:42that you know if they do have
24:42 --> 24:44pain that we do want
24:44 --> 24:48them to be treated for that
24:48 --> 24:51pain and to not worry both for physicians
24:51 --> 24:55and patients about the idea of addiction,
24:56 --> 24:58that's not to say that we
24:58 --> 24:59should forget about it,
24:59 --> 25:02but more that
25:02 --> 25:04cancer related pain is something that
25:04 --> 25:07should be treated and we shouldn't
25:07 --> 25:10under treat patients due to worry of
25:10 --> 25:12addiction as the data has not quite
25:12 --> 25:14shown that there are higher rates
25:14 --> 25:16compared to the normal population.
25:17 --> 25:19Yeah. One of the other questions
25:19 --> 25:22speaking about cancer related pain is
25:22 --> 25:26that for some patients we actually treat
25:26 --> 25:30cancer related pain with radiation.
25:30 --> 25:31And in other circumstances,
25:31 --> 25:34we talk about radiation as we
25:34 --> 25:36talked about just now potentially
25:36 --> 25:38having a side effect of pain.
25:38 --> 25:40So can you talk about
25:40 --> 25:41that kind of dichotomy?
25:42 --> 25:45Yes, so you know these are two
25:45 --> 25:48separate processes and two different
25:48 --> 25:51indications as as the
25:51 --> 25:54radiation induced pain,
25:54 --> 25:56you know we think of that as more
25:56 --> 25:59of a acute inflammatory reaction
25:59 --> 26:01that tends to be self limiting.
26:01 --> 26:04So when we're treating patients with you
26:04 --> 26:06know cancer that's spread to the bone,
26:06 --> 26:09usually I'd say about 1/3 of
26:09 --> 26:11patients may experience some kind
26:11 --> 26:14of acute inflammatory reaction.
26:14 --> 26:18And it's what we call a pain crisis
26:18 --> 26:20and you know generally these tend to
26:20 --> 26:23resolve within a couple weeks now for
26:23 --> 26:25the 2nd aspect or cancer that's actually
26:25 --> 26:27spread to the bone that's causing pain,
26:27 --> 26:31radiation can actually be used to shrink
26:31 --> 26:34the spots or the spot that's in the
26:34 --> 26:38bone and reduce some of that effect
26:38 --> 26:41or compression on the bone that the
26:41 --> 26:45cancer is causing and so more long term
26:45 --> 26:47we can expect patients to be
26:47 --> 26:50more pain free or have
26:50 --> 26:51reduced amounts of pain.
26:51 --> 26:54And one of the nicest things that
26:54 --> 26:56I love about radiation is that
26:56 --> 26:59patients may come in who are on
26:59 --> 27:02opioids or pain medications and we
27:02 --> 27:05may be able to treat them with a
27:05 --> 27:07metastatic bone lesion using radiation.
27:07 --> 27:10And a month or two months later,
27:10 --> 27:12they may not need opioids anymore or
27:12 --> 27:15they may need significantly less opioids.
27:15 --> 27:16And that's always satisfying.
27:18 --> 27:20Certainly when we think
27:20 --> 27:22about quality of life of patients,
27:22 --> 27:24it sounds like radiation
27:24 --> 27:26therapy can certainly play a
27:26 --> 27:28role in ameliorating that.
27:28 --> 27:30Talk a little bit more about kind
27:30 --> 27:32of where you see radiation therapy
27:32 --> 27:35going long term in terms of the
27:35 --> 27:37care of patients with cancer.
27:37 --> 27:41I think one of the more
27:41 --> 27:44exciting aspects that we have
27:44 --> 27:46people in our department working on is
27:46 --> 27:49combination of radiation
27:49 --> 27:51and other systemic therapy agents.
27:51 --> 27:54One thing that we're
27:54 --> 27:56trying to explore the interaction with
27:56 --> 27:59is radiation and immunotherapy to see if
28:00 --> 28:02radiation can kind of energize the immune
28:02 --> 28:05response to better attack cancer cells.
28:05 --> 28:07And that's currently
28:07 --> 28:09being explored in trials.
28:09 --> 28:10And, you know,
28:10 --> 28:12other aspects like DNA damaging agents
28:12 --> 28:15are kind of being seen whether they can
28:15 --> 28:18work in conjunction with radiation.
28:18 --> 28:19In a synergistic manner.
28:20 --> 28:23I think the future really is kind
28:23 --> 28:26of looking at radiation with some of
28:26 --> 28:29these novel agents and seeing if we
28:29 --> 28:32can combine them in a more synergistic way.
28:32 --> 28:35Doctor Vikram Jairam is an assistant
28:35 --> 28:37professor of clinical therapeutic
28:37 --> 28:39radiology at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu,
28:43 --> 28:46and past editions of the program
28:46 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Providing Quality of Life during Survivorship August 21, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095