The Doctor/Patient Relationship
One important aspect, again with the use of adjunctive chemotherapy is trying to ameliorate and lessen some of the side effects. So from the nausea/vomiting standpoint, there’s some very good medications out there that will certainly significantly reduce the nausea and vomiting; medications that are far better than the medications that I had available 30 years ago now when I started in my specialty. However, these medications while they significantly reduce the nausea/vomiting, they’ve got their own set of side effects because there is no drug that’s a safe drug, no drug that’s side effect free. So the side effects that we commonly hear about after the fact are headache, which is a known side effect of a drug called “Ondansetron” or another drug called “Kytril”. These are to be expected. The other side effect that we hear about commonly is constipation. So again, in our practice, in many practices, we try and go after this proactively. So we’ll inform patients about these potential side effects so that they’re not caught by surprise. We’ll advise them about the use of laxatives to try and avoid the constipation that follows the use of some of these antiemetics. Again, I think from the symptom management standpoint, there’s a great deal of emphasis right now on trying to manage and minimize some of the symptoms associated with chemotherapy; so one area that’s really being focused in on is the area of nausea/vomiting. From the standpoint of trying to minimize another known side effect, which is mucositis, which fortunately doesn’t happen all that often; although again, in the appropriate patient, it could be a debilitating-type of side effect. The mucusitis means sore mouth. It’s related to an inflammatory process that occurs in the mouth. Patients tend to notice this somewhere around 10 to 12 days after the administration of chemotherapy. There’s some drugs that do it, not uniformly, but there are some drugs that are associated with the development of mucusitis, such as Adriamycin, much more readily than other drugs but that’s another thing that we try and manage. Ways of doing that have to do with dilute solutions of sodium bicarbonate. Bicarbonate is the active ingredient in baking soda, so using that as a swish-and-spit will sometimes lead to significant reduction in the irritant effect that one is experiencing. Other ways of doing it are using a cocktail of oral antibiotics in conjunction with something called “lidocaine”. Lidocaine’s a topical anesthetic. So again, one tries to… One, from the physician and the treatment team’s standpoint, we’re actively trying to minimize some of these side effects so that the experience, while it’s never a pleasant one, isn’t too debilitating.
Another area that’s being focused in on is again trying to minimize some of the bladder irritation associated with some of the chemotherapy drugs, so what we tell patients to do before chemotherapy is to make sure that they’re well hydrated, that they’re drinking lots of fluids. We encourage fluid intake during the time that they’re receiving chemotherapy, encourage the fluid intake subsequent to its administration so that we flush the drugs out of the bladder and try and minimize that type of side effect.
From the patient’s perspective, feel free to ask your questions, okay. Again, I think in the doctor/patient relationship, there isn’t a question that is too trivial. There isn’t a question that is a dumb question. There isn’t a question that isn’t relevant. Obviously if it’s important from your standpoint to know, it’s important to ask. What you should expect from the physician’s side is an explanation, an answer. Sometimes it may not be the answer that one’s looking for but you deserve an answer to the question and you deserve someone taking the time to try and answer the question appropriately. Many times when we’re in a dilemma, okay, as far as just to cite an example: Yesterday I saw a very young woman who had node-negative breast cancer and the dilemma was that if we sort of read the state of the art six, seven months ago, she would have been a candidate for chemotherapy followed by Tamoxifen. But the state of the art has changed and the dilemma that we get into right now is: Who’s an appropriate candidate for, who isn’t? But recognize as I told this young woman yesterday that things aren’t black and white and in medicine, there are a lot of gray areas. So she had her tumor sent off for genomic testing. This is looking at genes that are expressed that tend to convey a prognosis. The testing process that’s done is something called “Oncotype DX”. It’s readily available. It’s approximately a $3,000 test. Insurance companies are paying for it and it is informative in this respect: If one score is low, then what we know about this test based on the information at hand is that from a prognostic standpoint, a woman who has no negative breast cancer may not require any chemotherapy. One may get away with hormone therapy such as Tamoxifen. Conversely, if the test score comes back high, then there’s clearly a need for chemotherapy followed by appropriate hormone therapy. But then we get into the gray area, okay. A test score that is neither low nor high, what to do? No answer, okay, no answer to date. A very large study that’s going on in this country that’s tempting to define the answer about what to do in this intermediate score category, and the way that I left things with this woman yesterday was, “Well, if it’s low, obviously you may be able to avoid chemotherapy. It’s high, you definitely need it but if it’s in the intermediate range, we don’t know the answer; but given the age, given her set of circumstances as I explained to her yesterday, if we’re going to make a mistake, the mistake is going to be an over-treatment as opposed to under-treatment. So that’s the dilemmas that we get into. Sometimes we don’t have all the answers. It’s getting better. We’re clearly getting more information. We’re advancing the state of the art. Thankfully, the incidence of breast cancer is going down in this country. Thankfully, the number of deaths from breast cancer is declining on a year-to-year basis, but obviously, we don’t know everything there is to know about the disease.
One of the questions that come up from time to time is the issue of adjuvant versus neo-adjuvant, and there are clearly instances where neo-adjuvant therapy, which is the pre-surgical use of chemotherapy, is an appropriate thing to do. So I don’t think that there’s any controversy. If a woman has a tumor greater than five centimeters in size, which equates to two inches, I don’t think that there’s any controversy about using neo-adjuvant therapy in that setting. The rationale behind it is to try and reduce the tumor size and maybe convert what would have been a mastectomy, a modified radical mastectomy into a situation that lends itself to a lumpectomy and radiation therapy. The negative about neo-adjuvant chemotherapy is that you really don’t know the status of the lymph nodes at the time that you’re administering the drug, the series of drugs. So somebody node-positive, we don’t know. What’s the number of nodes positive? We don’t know that either, and that’s very difficult information to ascertain after-the-fact. So again, in many instances, we assume the worst. We assume that we’re dealing with lots of node positivity, treat a patient appropriately based on that fact. Again, maybe erring on the side of over-treating someone, but the tradeoff is greater ability for breast conservation, greater ability to proceed with lumpectomy and radiation therapy. In a study that has been done in this country that tested neo-adjuvant versus adjuvant chemotherapy, certainly no difference in terms of disease-free survival, whether you get the chemotherapy upfront or whether you get it post-surgically.
