ESMO 2010

Professor Dorothy Keefe – The University of Adelaide, Australia

Pain management and the treatment of cancer patients with low blood counts

I had a session where I was a poster discussant about posters in palliative and supportive care. There were three posters that I had to discuss, two of them were about pain management and one of them was about drops in blood counts and how that could be managed in patients with cancer.

The pain ones are really interesting because, as you know, access to pain medications around the world is very uneven and even where it is readily available there are problems with deciding what doses you should use and what drugs you should use. So these two studies were looking at different ways to make the pain better using different agents and different ways of administering the pain relieving drugs. So one of them was using a nasal spray, which is a really clever way of getting drugs in when people have problems swallowing and that sort of thing.

The other one was looking at a combination of a standard opioid and an extra drug for neuropathic pain and looking at different ways of raising the doses of the two to come up with the best outcome for the patients, and again that was a good study because it showed that you could do different things with the two drugs and have a better outcome.

What was the topic of the third presentation?

That was a study looking at the differences in use of supportive care drugs for low blood counts in different countries. So we have guidelines that are made by ESMO and made by the US cancer organisations that say that we should use these drugs to stop patients who are having chemotherapy from having low blood counts. However, the regulatory agents in the different countries don’t allow those drugs to be used. So, for example, in Australia where I live we can’t use the drugs in many of the solid tumours. So this was a study, it was industry sponsored and it was looking at using the drugs according to the guidelines in the countries and seeing whether that had an impact on the amount of infection and the toxicities of the treatment. It’s difficult to tell from the particular study whether it really did have a major impact.

What were the outcomes of the supportive and palliative care sessions?

There were well over a hundred people there and the room was full. There was a lot of discussion about how you would monitor pain and what sort of studies you could do in pain – how you can do good clinical studies that look at supporting the patient, not just curing the cancer. And that’s a very important thing about supportive and palliative care that we’re not always talking about curing the cancer, we’re talking about looking after the patients while we try to cure the cancer.

Were there any key messages that patients could take away from this session?

I did also chair a session in the patient seminar which was about long-term rehabilitation and that was, again, a very interesting session because the patients and the care-givers were there and they have a very different focus from us. It’s very good, actually, for oncologists to spend time with the patients in those sorts of seminars because then we hear what really is important to them.

What were the outcomes of that session?

Very positive again, talking about different sorts of rehabilitation – psychosocial rehabilitation, physical exercise; talking about how looking after the patients is really important, getting them to exercise is really beneficial, and nutrition. So generally living a healthy lifestyle and being looked after properly is good for you.

Can you tell us about the targeted therapy session you were involved in?

The toxicity of targeted therapy session was a real highlight of the conference for me. There were probably over 400 people in the room, which is a huge number at a supportive care topic in a mainstream cancer conference. And there were apparently a couple of hundred more people in the overflow room, so it was a very well attended session.

There were three topics that we discussed and they were skin toxicity of targeted therapies, gastrointestinal duct toxicity of targeted therapies and cardiovascular toxicities of targeted therapies. The reason this is so interesting is the targeted therapies are aimed at treating patients more successfully with less toxicity and of course what’s happening is we’re finding that there are different toxicities from these new agents than there were with standard chemotherapy, but there are still toxicities. Because they are different and because they were unexpected, we didn’t know what to do with them so the science of how to manage these toxicities is catching up with the clinical practice. The clinicians are using the drugs, they’re getting into trouble because the patients are having problems and we were discussing the science of how to prevent and treat, manage those side effects.

So Mario Lacouture from New York gave a wonderful presentation about the skin toxicity and how you can prevent that by using skin washes and antibiotics. I talked about the animal model that we’ve developed for diarrhoea in targeted therapies, which is showing exactly the same sorts of problems as you see in patients and then we can use that to try anti-diarrhoea measures and see if they work and then try different agents and see if they produce the same diarrhoea and work out what the mechanism is and how best to fix it. Then we had a very good talk on the damage that happens to the heart by Thomas Suter, looking at which bits of the heart damage are preventable and how much you need to intervene and how you can make the drugs more acceptable for the patient. So it was a very exciting session.

What kind of cardiovascular toxicities do patients encounter?

We get all sorts, we get changes in muscle function and reduction in how well the heart pumps and we also get changes in blood pressure, which is very unusual for oncologists, they don’t normally manage blood pressure but these drugs cause high blood pressure and so we have to work out how to manage that as well. So we’ve all got to learn quite a lot of different things about how to manage these new agents.