NYC Scarborough Supportive Therapies

NYC Scarborough Supportive Therapies


>>It’s a pleasure now to introduce Dr. Bethann
Scarborough. She the Co-Director of our Ambulatory Palliative Care Center at Mount Sinai and
I think the best intro for this is that the paradigm of oncology is that palliative care
is important from day one of oncology, not when we’ve exhausted all the treatment options.
So, she will follow up on that theme.>>Okay. Hi everybody. My name is Bethann
Scarborough and I am one of the palliative care physicians at Mount Sinai and as Dr.
Chari graciously mentioned in his introduction what I really do is provide symptom care and
support for patients as they’re going through treatment for their multiple myeloma. So I’m
going to walk through a couple of the ways that we can help support patients in terms
of symptom control over the many years that you may be living with this illness; perfect.
So myeloma has multiple effects throughout the body I think you’ve heard throughout the
morning. And what I’m going to do is I’m going to go through the slides and I heard a couple
of comments that were directed to Dr. Chari specifically related to neuropathy or maybe
some other components of the illness. So I’ll save some time to talk a little bit about
those things at the end. So as you’ve heard throughout the morning myeloma has multiple
effects on the body. It affects bone health. It affects low blood counts and it affects
kidney function. And bone disease is really the most common complication of multiple myeloma.
It occurs in the vast majority of patients and in essence in normal patients there’s
a balance between new bone hat’s being made while old bone is being broken down. And this
is a constant remodeling and turnover process. And in myeloma this process doesn’t happen
normally or in a healthy manner. So bone is actually being broken down faster than it
should because of the myeloma. When the bone is broken down too quickly it releases calcium
into the body, which can have effects in terms of how it makes you feel and can actually
have effects on your kidney function as well. Because of the bone disease patients are often
at risk of fractures. Many times patients may have already had a fracture in the bones
around their spine, so what we call a compression fracture. And if that actually impinges on
the spinal cord at all it can cause neurologic damage especially to often lower extremities
of the body. So bisphosphonates are one of the major treatments for myeloma related bone
disease and what they do is in this schematic you can see that the orange cell in the middle,
this is a magnified image of bone. The orange cell that says OC on it is an osteoclast and
those are one of the cells that are involved in breaking bone down. And what the bisphosphonate
does is it goes and it blocks the function of those osteoclasts so that bone is broken
down less rapidly. The bisphosphonate does not help you build new bone. It just slows
the rate at which bone is broken down. And as a result this really decreases pain and
can decrease fractures and in some studies has been shown to decrease skeletal events
by 50%. The dosing of the bisphosphonates is usually once every month or so and can
be given with other treatments. There are two main medications that are often used.
One is called zoledronic acid or Zometa. The other is called Pamidronate. Zometa is a little
more commonly used today because it’s been shown to improve survival and it also can
be given in 15 minutes, which is a lot more convenient for people who may be coming and
going to and from work or other things that they’re doing rather than having to sit through
a two hour infusion of Pamidronate. There are side effects to these medications. Reduced
kidney function is a potential side effect for patients if they receive a Pamidronate
infusion in a shorter time period than two hours. So it’s not really the kind of medication
where you can just speed it up and give it a little bit faster. There is a risk of fracture
of the femur, which is a little counter-intuitive when you think about the fact that these medications
are protecting your bone health. And there’s the thought that in limiting the way that
bone is turned over there are tiny little microfractures and microstresses in certain
areas of the femur that can eventually over many many years lead to a fracture of the
femur. And evidence is mixed on this. There are some studies that show this association
and there are some that do not. And finally there’s a risk of osteonecrosis of the jaw.
And this is something again that the risk accumulates with more exposure to a bisphosphonate.
So, in patients who have been getting Zometa for over two years and are undergoing dental
work, there’s about a three percent chance that they’ll have damage to the bone in their
jaw. And that bone can even in some cases become exposed, which can be quite painful.
So that’s something that can be prevented with good oral hygiene and dental health.
So it’s really important to talk to your dentist if your doctor recommends a bisphosphonate
to let your dentist know that you’re going to be getting this medication and to really
be vigilant over time. It can be easy when you’re getting a medication every month for
two or three or four or five years to forget about how important it is to maintain your
dental health. So it is important to be vigilant over time and maintain your relationship with
your dentist. In addition there are treatments available for bone damage that are procedures
and these essentially stabilize the spine. A vertebroplasty and kyphoplasty are similar
procedures. Vertebroplasty inserts cement into the bone and really kind of expands it
to the maintain the height of the bone and a kyphoplasty inserts a balloon into the bone
and then a cement structure is inserted into that area to sort of maintain the height of
the bone and protects against a further fracture. Both of those procedures can stabilize the
bone and can reduce pain. In addition there is radiation therapy for pain relief. So I
believe earlier in one of the talks today you were shown some pictures of bone disease
on imaging. A picture of lytic lesion in the humerus and some in the skull. For example,
if someone has a lesion in their arm bone that could be treated with a directed radiation
to relive the pain in that area and perhaps spare the person of requiring systemic medications,
oral medications for pain relief if they just have pain in one area, okay. There are other
medications that may help treat bone problems. Both of these are being studied. The first
one denosumab, XGEVA is something called a RANK ligand inhibitor. Rank LIGAND is thought
to be the final common pathway in bone destruction. And this is currently approved for patients
who have bone disease from a solid tumor, which would be something like a lung cancer
or a colon cancer that’s spread to the bone and it’s being studied in other populations.
The second medication as well is an active [inaudible] inhibitor and again this is a
substance that’s involved in bone health and bone turnover. So if you inhibit the substance
you can slow the rate of bone breakdown and both of these are under investigation. So
you may hear your doctors talk about these over the next few years as they become better
studied, okay. There are also effects on your blood counts throughout the body. So anemia
or low red blood cells, low white cells is called neutropenia, which puts people at risk
of infection and low platelets is what we call thrombocytopenia. When someone has low
platelets it puts them at risk of bleeding complications and I’m going to talk a little
bit about anemia and neutropenia. So our red cells have multiple functions throughout the
body and some of their primary functions are to carry iron around in the body as well as
to transport oxygen. So when people have a low red cell count they can feel very tired.
They can actually feel short of breath or feel like their heart is palpating and beating
very quickly. There are causes of anemia that can be checked with a simple blood test. So
your doctor can check your blood for your iron levels, folate levels, vitamin B12 levels
and easily give supplements if those levels are low. In addition there are medications
that can be used to increase the number of red cells that your body produces and also
at times you may require a blood transfusion in order to rapidly boost the number of red
cells in the body. It is important to be aware of the signs and symptoms of a low red cell
count, because if you suddenly develop chest pain or difficulty breathing it should prompt
a call to your physician who may ask you to come into the office or even go into the emergency
room to be evaluated. Neutropenia is what we call a low white cell count and our white
cells are the cells that are responsible for fighting infection. These can be reduced from
the myeloma or from the myeloma treatments. So again, routine health maintenance becomes
even more important; getting your pneumonia vaccine and your flu vaccine if you have had
chicken pox as a child getting a shingles vaccine, to protect against the herpes zoster
virus that causes chicken pox and shingles. Making sure that you are vigilant for signs
of infection, that your doctor may recommend you get after chemotherapy they anticipate
the chemotherapy will make the blood cell count drop. They may give you a shot of something
called Neupogen, which stimulates the body to create more white cells. There are also
effects on the kidney and I think that this has been discussed earlier this morning. But
this is checked, your kidney function is checked and monitored with a simple blood test and
you can, you may be aware of a change in your kidney function if you suddenly notice that
the amount of urine that you’re making has decreased. That could be one side of it, sign
of it. There are other causes in addition to myeloma, high blood pressure and diabetes
are other causes and Dr. Chari mentioned earlier that some medications, particularly over-the-counter
anti-inflammatories can be quite damaging to the kidneys. So it’s important to know
ways to manage your pain and other symptoms without having to resort to anti-inflammatories
and I’ll talk about those in a minute. There are also supportive care if your kidneys are
damaged, fluids to keep yourself hydrated and flush any proteins out of the system.
Plasmaphoresis is a way of filtering proteins out of the sort of liquid component of the
blood, so filtering out the actual proteins that are present in the blood, but not filtering
out the red cells or the white cells. And then in severe cases of kidney failure dialysis
may be recommended which actually replaces the entire function of the kidney. And then
finally there are a lot of lifestyle modifications and these are some of the things that I think
are the easiest things to talk about and the hardest things to do. So it’s easy to talk
about eating better and it’s really important to eat sort of what you’re hungry for when
you’re hungry for it, but make sure that you’re eating as healthy as possible. You may have
changes in your taste that come up from treatments that you get for myeloma. You can talk to
your doctor about whether or not you can take a general multivitamin. The zinc that’s in
multivitamin can actually be protected in terms of your taste bud health. So that can
be one simple thing that you can do providing it does– there’s nothing in it that interferes
with your chemotherapy that can be quite helpful in allowing you to have as good taste sensation
as possible. It’s easy to talk about getting more exercise but that can be really hard
to do if you’re feeling very tired and worn out from either the treatment or the myeloma
or just the logistical aspects of care. So one of the things that I commonly recommend
to people is to really think about being as active as possible throughout the day and
that varies for everybody. For one person activity may be walking across this room.
For another person it may be walking three or four miles a day. But it’s important to
be able to kind of push yourself to the point where you feel good and invigorated and energized
from the activity without pushing yourself past that point and feeling exhausted from
it and knowing that there are going to be new limitations that you have in terms of
your activity level. Physical therapy is also extremely helpful. One of the things that
often happens is people get pain from the bone disease and they tend to be a little
less active and it’s a vicious cycle. So, if in particular there’s someone who has a
compression fracture in the back or you know pain in the hip or something that’s limiting
them from really moving around the way they want to, physical therapy with a good physical
therapist who may ask you for results of your imaging to know where the myeloma actually
is can be really helpful in strengthening the muscles around the bones and making sure
that you can be as safe and active as possible. Decreasing alcohol consumption is important
because alcohol affects your body’s ability to make normal cells, your red cells, your
white cells, your platelets and then minimizing or eliminating stress I think is another thing
that’s really easy to talk about and can be hard to do. So when we think about living
with multiple myeloma patient’s live much longer today with the treatments that are
available and it’s really the healthcare team’s job to help you live as well as possible for
as long as possible. So there are many common symptoms in myeloma, but fatigue is one of
them. Fatigue can actually be improved. There are studies that show that energy level improves
when people are a little bit active throughout the day. And you know fatigue is different
than being tired. Everybody gets tired and when you rest and get a good night’s sleep,
that tiredness goes away. When you’re truly fatigued from living with cancer oftentimes
rest doesn’t completely relieve it or refresh you and make you feel better. So it can actually
be important to get up and move around a little bit throughout the day even if you’re feeling
like it’s hard to do that, to just push yourself a little bit. Bone pain we’ve talked about
some of the treatment options that are available. There are many patients who get relief of
their bone pain with pain medications, opioids such as Dilaudid or oxycodone or morphine
can really be helpful in controlling pain so that you can continue to function and not
have your functional status limited by pain. And this is especially important when you
have to avoid medications like ibuprofen or Advil or Aleve. There’s also neuropathic pain
and the thing to remember with neuropathy is that some people have neuropathy from the
myeloma itself. Some people will have neuropathy from a treatment they’ve gotten for the myeloma.
So typically what we look for when someone has a neuropathy that’s come up or developed
as a result of a myeloma treatment or a chemotherapy we monitor the patient very closely for the
first year after they stop getting exposed to that agent and we look for any improvement
in them. There are many medications that can be used to treat neuropathy. There are medications
like Gabapentin or Neurontin which can be used as often a first line medication. If
that’s unsuccessful we move onto a second line medication such as Lyrica. Many patients
will actually get treatment for their neuropathy with an antidepressant since many antidepressants
have activity against neuropathy, particularly chemo related neuropathic pain. And then the
important thing to also keep in mind is that what we’re looking for with these medications
is about a 50% reduction in the symptoms. And some people have a lot of tingling and
pins and needle sensation. Some people predominantly have numbness when they have neuropathy. The
numbness is actually much harder to treat than the tingling and pins and needles. But
it’s important to be as active as possible because activity and physical therapy can
actually improve the neuropathic pain. It’s important to check your feet every single
day and make sure that there’s no skin breakdown, that you don’t have a sore on your foot, because
if your foot is numb you’re not going to feel it when it hurts. And it’s important to be
vigilant with that but there are many medications that we can use to treat neuropathy with a
goal of keeping you as functional and dependent as possible. Depression is also something
that often comes with a serious illness. And I think with any of these symptoms the very
important thing to remember is that any of these symptoms can be treated. And many times
I see patients who are really struggling with a symptom and they’ve really never brought
it up to their doctor because they think that it just comes with the territory of being
sick and nothing can be done about it. And I’d really encourage you to talk to your doctor
about any symptoms that you’re having even if you think that they’re very minor because
there is quite possibly ways that they could be treated. And finally the last sort of thing
that I want to leave you with and then you can take any questions is that there are significant
psychosocial aspects to living with this illness for months and years and many years. And this
symptom level really does affect social functioning. For people who have a lot of pain, who are
very depressed they may withdrawal socially. They may not want to interact in the same
way that they used to. And supportive services are really important for both patients or
caregivers. And I’m wondering just briefly if I can get a show of hands for anybody in
the room who has multiple myeloma. Who’s living with myeloma? Great, and a show of hands of
people who are caregivers or loved ones of people with myeloma? Right, so you can see
that the audience here is really split and it’s not just patients that are affected by
this illness but caregivers are also affected and giving support is really critically important.
This is a treatment that’s primarily out-patient based which means you come, you get your treatment
and you go home. So what happens at two in the morning when you have pain or you’re vomiting
or you’re having something else going on and you don’t know if it’s a side effect of the
treatment or not? There are the logistical aspects of care, coming back and forth to
treatment. Does that mean that you have to take time off of work or your loved one has
to take time off of work? And what does that mean for you financially? And really making
sure that you have that support makes people weather the storm. When you’re living with
an illness for many, many years there are going to be good times and bad times and ups
and downs. And whether that support is a spouse or a partner, a family, another family member,
a friend or neighbor, a religious community, a myeloma support group or a counselor a therapist
it’s important to have a network to support you both in celebrating the good times and
in supporting you through the difficult times. So in summary there are many approaches that
can be used to reduce the impact of the complications that are common in multiple myeloma. We have
medications and interventions that are possible for bone disease. We have ways of supporting
blood counts and making sure that you don’t suffer the complications of low blood counts
as well as protecting kidney function. And finally to make sure all of you really understand
the physical and psychosocial burdens of this illness and that as your healthcare team there
are many people who are available to help support you through this. Thank you. [ Applause ]>>We have some time for a couple questions.>>Yes. You mentioned eating well. What foods
do you recommend to help you? For example, they always talk about releasing calcium.
Is there something you should avoid or red blood cells that are reduced is there something
you should add, and the simplistic way of creating better eating habits.>>Great question. So many of the things that
you can do to help especially in terms of anemia with nutrition are eating green leafy
vegetables, eating a diet that has protein. So chicken or fish or even nuts can supply
that protein. You may be encouraged to use a supplement so there are some patients who
use nutritional supplements such as Ensure. And then the other part of your question in
regards to the calcium you do want to be careful with the calcium intake. So one of the things
that I have seen some patients do is they may have heartburn or some kind of reflux
or indigestion and they’re taking a lot of Tums, and that can be dangerous if you do
have multiple myeloma or any illness where you’re at risk of having a high blood calcium.
So I would caution you to avoid the excess use of calcium supplements.>>Quick question. I wanted to know, what
do you think about vitamins, supplementing what you eat with vitamins because there really
is no change in your diet per se.>>So I think that the vast majority of times
vitamins do not do any harm and potentially can do a lot of benefit. I think the only
caveat to that is if there are new treatments or particular treatments where something in
the vitamin would interact with the chemotherapy. That is something to talk to your doctor about.
So there are some patients who cannot take a multivitamin when they’re on certain chemotherapies
because it actually reduces the effectiveness of the drug.>>Just to add to that one point vitamin C
and green tea in the laboratory helped kill myeloma cells, but there’s still some data
that suggests that in high doses vitamin C and green tea extracts can interfere with
Bortezomib and Revelcade. It’s always good to double check with your physician with the
specific regimen that you’re on.>>I wanted to ask how could you tell, how
can a physician tell if neuropathy is due to the actual myeloma or the medications that
were given?>>It is a very, very careful history in trying
to track back exactly when the symptoms started. So this is more difficult in patients who
have something else that may cause neuropathy like long-standing diabetes. That could also
cause a peripheral neuropathy. But really most patients will know if they had neuropathy
before they started treatment or if it started afterwards. And for many people they’ll come
in to see me and they’ll say, “Well I was fine. I never had this until you know three
months after I started my treatment or three weeks after my treatment I started having
this sensation.” And that’s why every time you may go to the doctor they ask you questions
about numbness or tingling in your fingers or toes, if you can close buttons on your
shirt, if you can tie your own shoes and manage zippers and stuff like that, because there
are times when treatment doses are adjusted based on the severity of neuropathy. But it
really is paying attention to the timeline for when the symptoms first started and if
it was before or after the drug. Sometimes when the neuropathy is from the myeloma and
the myeloma is treated the neuropathy gets better.>>Can you just back to your statement about
the singles vaccine. Is it recommended or not recommended for myeloma patients?>>So the shingle vaccine is currently not
approved yet for myeloma because it is a live vaccine. So it’s much better to take the preventative
medications, the proteasome inhibitors both Bortezomib and Carfilzomib. Twenty percent
of patients when getting those drugs can have shingles. So everybody getting those should
really be on a preventative medication and that is the current recommendation as opposed
to getting the vaccine.>>So Dr. Chari just doing a follow up, would
that be the preventative medication would be started with the chemotherapy?>>Yes, at the time of starting Bortezomib
and Carfilzomib and probably until about three months after the last does those medications
should be continued.>>Oh, I’m getting time. I’m told that it’s
time to stop, but thank you very much.>>Thank you. [applause]

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