An Inside Look at Lung Cancer and Palliative Care

Coping with side effects from lung cancer and its treatment can be one of the most stressful parts of facing a cancer diagnosis. Many people don't know there is a medical sub-specialty called palliative medicine (sometimes called supportive care) that is aimed at helping patients manage their side effects and improve their quality of life. It is recommended that most lung cancer patients receive palliative care at the start of their lung cancer treatment, regardless of prognosis. We sat down with oncologist and palliative care specialist, Cardinale B. Smith, M.D., Ph.D., to learn more about palliative care and lung cancer.

1. How did you get interested in oncology and palliative care?
   I always knew I had an interest in oncology. In medical school, I enjoyed learning about the pathophysiology of cancer and got really excited about new treatments that were moving the field forward and helping patients live longer. When I was an intern in residency, I was taking care of this patient with stage 4 prostate cancer. His oncologist was lovely and they had a great relationship. However, the patient was in a lot of pain and didn't know why he was still on treatment. The oncologist was telling him to hold out for a clinical trial. They finally called a palliative care consult. When the palliative care doctor arrived, the man said, "Why do people keep doing this to me?" and the palliative care doctor said, "Tell me what you mean. What is important to you?" I knew right then that if I was going to be a cancer doctor; I was going to be one who had a skillset to be able to ask my patients about their needs and preferences.  
2. What does palliative care look like in practice?
   It is different depending on where you go. The thing about palliative care is it spans across care settings. It could be inpatient, outpatient, home based or in a nursing home. It is really different depending on where you are. What we consider to be good quality palliative care is an interdisciplinary team made up of a physician and a nurse as well as other supportive care professionals, such as a social worker, chaplain, art therapist, massage therapist, etc. It is an interdisciplinary team that can do a whole patient assessment and treat not just the physical part, but the emotional part, and help the caregivers, too. It's not just the patient going through it, it is the family.
3. How does a person ask for palliative care?
   You can ask your oncologist for a palliative care referral. Unfortunately, there is a work force shortage so palliative care is not available to everyone everywhere. You can also visit Getpalliativecare.org to find board certified palliative care physicians near you.
4. What do you do if there isn't a board certified palliative care specialist close to you?
   That's the hard part. As a field, we are struggling with this. We are trying to move forward with primary palliative care. So, the front line provider (like the oncologist) handles basic palliative care, even though some patients will need a more specialty-level care. Talk to your provider about why you think you need specialty-level palliative care so they can help guide you. Maybe you are struggling with some severe side effects and having a hard time getting  them under control. These are some reasons why you may need specialty-level palliative care. We are also looking into telehealth, so specialists can provide care without being in the same room as the patient.
5. What are some of the most common side effects you see in lung cancer patients?
   Most common side effects I see in lung cancer patients are shortness of breath, pain, fatigue and loss of appetite.
6. How do you help?
   For shortness of breath, I see if the patient needs oxygen therapy. We also recommend avoiding noxious smells, having a fan and even opioids in very low doses can help decrease the sensation of shortness of breath.

    

   Combatting fatigue is a bit harder. We tell people to conserve their energy so they have more time to do the things they must do. The more activity you can do, the more it helps with fatigue. Aim for 30 minutes of activity three times a week where you get your heart rate up just a little. Complementary and alternative medicine like yoga, acupuncture and mindfulness can help too. There are not great long-term medications; however, sometimes stimulants can help counteract sleepiness from medications.

    

   Addressing loss of appetite is also difficult and we struggle with it a lot. There are many causes. We try to rule out reversible causes like heartburn, constipation, nausea and even depression. There are medications we can use to help stimulate someone's appetite. They work about a quarter of the time but they can be worth trying. If they don't work, we go back to behavioral type changes such as eating small meals throughout the day.
7. How are lung cancer patient's needs unique?
   Unfortunately, I think there is still a stigma associated with lung cancer. There is this sense on the part of the patient that there is personal responsibility and maybe there should be more suffering. Sometimes there is bias towards lung cancer patients amongst clinicians as well. There is a lot of underreporting on both sides so there is extra work that needs to be done to make sure patient needs are met. One other unique factor is that many lung cancer patients are older and have a smoking history, which means they have medical complications that make managing side effects more challenging.
8. What are some barriers people experience to managing their side effects?
   Pain is a major side effect that is challenging to treat. With the current opioid crisis, many patients fear they will become addicted to pain medication. On the systems facility side, where you live may determine whether or not you have access to opioids. Patients in poorer urban areas have less access to opioids than those who live in wealthier areas. There are more regulations and authorizations that can make prescribing these medications harder for patients who really need it.

Want to learn more? Register to watch our recent webinar "Coping with Lung Cancer Side Effects" on demand and hear Dr. Smith discuss more techniques for coping with side effects.