Multidisciplinary Approach to Treating CINV

Eric Roeland, MD: Going back to the previous point about who the best resources are for that information, I really lean on my nursing colleagues and the pharmacy colleagues because the pace of oncology, now, is such that I don’t think that physicians can keep up. Having a team-based approach is really the way to go, and it’s important to make sure that these patients know who to talk to.

Dawn Dolan, PharmD, BCOP: One of the things I always tell patients is, there are no points for bravery. This isn’t a situation where anyone should feel like they’re burdening the physician with information. You know, “I was sick,” and, like you said, it should not be an expected side effect. So, I always tell them, “If you have a hint of nausea, nip it in the bud.” It’s probably preferable that they’re a little drowsy for a short period of time, rather than starting that really terrible cycle of nausea, with potential vomiting and, then, getting into a dehydration situation. Then, it just perpetuates itself.

Lee S. Schwartzberg, MD: As a pharmacist, do you talk to the patients directly at your institution, or is that a nursing function? How does it work?

Dawn Dolan, PharmD, BCOP: It’s both. I don’t get to see every single patient. I don’t get to counsel every patient about their therapies, but they’ll often bring me in on a complicated patient. Of course, we’re having that conversation in the clinic, but then we go in and get to talk to the patients. Most of it’s nursing education, but they’ll sometimes bring me in when they feel like it’s a little complicated, particularly, for the delayed nausea portion—that’s one area where people are still not understanding and getting it right.

Howard Levine, PharmD: Our practice uses nurse navigation. Up front, we’re already talking to these patients. If the nurse navigator asks, we come in and talk to the patient about certain medications, including antiemetic use. We tend to find that physicians may set up the patient not to report. You say to the patient, “It’s really important that you get all of this therapy, because if I give you at least 90% of this dose and it goes according to regimen, you’ll have the best response.” So, the patient gets a problem and sees the physician at the next cycle. “How did you do?” They don’t want to say they did badly. They think, “Uh-oh, he’s going to delay my treatment. He’s going to reduce my dose.”

We have to get them over that. Typically, it comes back to, in the treatment area, all of a sudden, the question is answered differently. “How’d you do last week?” The patient is not scared of telling the nurse or pharmacist because, “They’ll help me.” But, they didn’t want to tell the physician. So, we try and educate. You can tell everybody, “We’re all here, in the same package, to help you,” but getting them over that initial fear to report the side effects is a problem.

Lee S. Schwartzberg, MD: I think it’s really important. The multidisciplinary team is great, and in larger practices, as you’re all saying, having everyone involved is a wonderful way to minimize this toxicity. In small practices, which there are still smaller practices in the United States where there’s 1-, 3-, 5-man groups, they may not have an experienced pharmacist. They usually have, now, an advanced practitioner, but not all do. So, we still have a little bit of education to do for the physicians. What I’m hearing from you is very interesting because really, we shouldn’t, as oncologists, be telling our patients not to tell us everything. It should be the exact opposite. “Tell us everything. We have ways to deal with this, and we’ll do better and we can still keep your chemotherapy at the doses that will be most effective.”

Howard Levine, PharmD: Right.

Lee S. Schwartzberg, MD: That’s really a very interesting way. Let’s talk about how we monitor patients in terms of what’s happening during that period of risk in that first week. Eric, can you talk about some tools that we have to utilize and to get some information from the patients?

Eric Roeland, MD: Something that I’m observing at a lot of institutions, now, is that even just a phone call 24 to 48 hours after leaving the infusion center and just having a nurse check in with a patient has been exceedingly helpful for a lot of our patients. And then, really pushing that to the next level—which would be using evidence-based questionnaires to try to quantify what that experience has been. There’s a couple out there—FLIE is one, and the MAT is the other.

FLIE is the Functional Living Index for Emesis, and MAT is the Multinational Association of Supportive Care in Cancer Antiemesis Tool. It’s important to recognize when to use each one. Both cover nausea and vomiting in the acute and delayed phases. But FLIE has been validated in the 3- and 5-day recall period, whereas MAT is really excellent for the 24-hour recall. I try not to double up on them. If you’re going to make 1 phone call, say at 3 days, the FLIE would be your choice. But, if you’re going to be checking in with patients over a 24-hour period, you would choose MAT.

Lee S. Schwartzberg, MD: Your point about having a nurse or a nurse navigator, which increasingly we’re all using and they’re wonderful to get some feedback and to be proactive, is really good. It’s hard for patients. Sometimes it turns out, on Friday afternoon, they decide that they’re calling with their nausea and vomiting. Then, it’s the weekend and, sometimes, they get admitted. All that can be prevented, to a large extent, if they call early and get appropriate supportive care.

Eric Roeland, MD: Yes.

Dawn Dolan, PharmD, BCOP: These tools are great, and validated, and they seem pretty easy to use. But, I’ll be honest, I don’t feel like people are using them, or are certainly not using them proactively. Are you guys getting the same experience?

Lee S. Schwartzberg, MD: I agree. We haven’t formalized that we’ve used these tools outside of a research setting.

Howard Levine, PharmD: Yes.

Beth Eaby-Sandy, CRNP, OCN: We haven’t successfully really used them, I think, more from a time-savings perspective. One thing I do advocate for patients to do, though, is to keep a diary or a calendar of how sick they were after your chemotherapy. Most of my chemotherapy regimens are every 3 weeks, so when they come back 3 weeks later, they say, “Oh, I didn’t think it was that bad.” And usually, their caregiver says, “It was terrible. What are you talking about?” So, writing down how you felt in that first week is helpful, because then, 3 weeks later, you can go back and see what you wrote, as opposed to not remembering later.

Lee S. Schwartzberg, MD: Or, that minimizing thing that Howard talked about.

Howard Levine, PharmD: I agree. We do that with all of our chemotherapies that people go out on, especially the orals. We’re saying, “Just write down a word on the calendar as a reminder.” Because, when you ask how they’re doing, that was within the last 3 days. And 3 weeks ago, or 2 weeks ago, they don’t remember that, for 4 days, they were miserable. They’re feeling great and you have to really remind them. We look at it and go, “Oh yeah, but you said this.” And the patient says, “Oh, that’s right.” We can remind that patient, “We could help you with that.”