Dr. Kenneth Miller, Pain and Palliative Care
January 13, 2008

Welcome to Yale Cancer Center Answers with Drs. Ed Chu and Ken Miller.  I am Bruce Barber.  Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and Dr. Miller specializes in pain and palliative care.  If you would like to join the discussion you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC.  This evening Dr. Chu speaks with his friend and co-host Dr. Miller who is a specialist in the area of supportive care and pain management and is the director of the Connecticut Challenge Survivorship Clinic and Program at the Yale Cancer Center.

Chu
Let us start off by defining for our audience what supportive care means.

Miller
It is the entire care environment for a patient who is being treated for cancer, outside of the therapy that they are getting for that disease.  Treating someone in a situation where the treatment is worse than the disease is obviously not a good situation. Our goal is to try to control symptoms; people are afraid of being nauseous, we don't want them to be, people are afraid of pain, we want to make sure we control it.  We try to make treatment and the entire process of going through an illness as easy as possible.

Chu
Truth or myth - when some people hear the term 'supportive care,' they think they have a very advanced stage of disease and that they are terminal, is that a truth?

Miller
That is a myth.  People deserve support, good care and good symptom management from day 1 for as long as they live, which we hope is going to be years and years.

Chu
It is an effort on our part to maintain quality of life while they're undergoing whatever type of therapy they are for their particular cancer.

Miller
Absolutely, if we look at diseases where we have wonderful therapy such as with the treatment of certain types of lymphomas, breast cancer, really many diseases, the people have a far better shot at doing well if their symptoms are controlled.  For example, if a patient is receiving chemotherapy and has a lot of symptoms and can't get the treatments on time, then we may not be giving them the optimal chance of being cured of the disease.  If we control symptoms so they can be treated with a full dose on time, they have got a better chance of doing well.

Chu
Supportive care is often referred to as the so-called fifth dimension of therapy, which I think highlights the importance of supportive care.  Can you explain what that means?

Miller
In many ways we also think of it as the fifth vital sign. Pain is typically the fifth vital sign.  We talk about blood pressure, impulse, respiration, and temperature.  We think of pain as being the fifth vital sign, but if we broaden it beyond just pain, all symptoms are another dimension of cancer care, and are important at the time of diagnosis, during treatment, after treatment for the long-term, and for being a healthy survivor of cancer as well.

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Chu
Since the time you and I were fellows, which was a number of years ago, we have become much better in terms of treating the symptoms associated with the various chemotherapy regimens that we have.

Miller
It has been fascinating in many ways because as more therapies become available for people with cancer, the side effects become different then when you and I were trained. That has required a sort of broadening in all of our thinking.  For example, some of the oral medicines now are given through IV for colon cancer, which is you expertise, and cause a very unusual skin rash. Another one causes problems with neuropathy. It has been challenging and exciting to find new ways to deal with that so that patients can continue treatment and have a good quality of life.

Chu
The typical symptoms that we associate with chemotherapy are nausea, vomiting, mouth sores, cramps, and diarrhea. We have also made significant advances with those symptoms.

Miller
We have, and one of the things that patients ask almost all the time is, "Will I be sick?"  Sick often means - "Will I be nauseous?"  We have a lot of new medications available to prevent nausea and soon we hope to be opening our own trial, our own clinical research, looking at a different combination of antinausea medicines because there are still a small percentage of people that get nauseous and we would like to eliminate that.

Chu
The immediate focus when we first see a patient with newly diagnosed cancer is the treatment, but clearly supportive care needs to be integrated into the treatment plan.  How do you go about doing that?

Miller
One of the nice things about the Yale Cancer Center is a strong commitment to multidisciplinary care. There are all the different physicians involved, but also nursing and pastoral care and all those different elements. There is a strong commitment to symptom management in each of those groups. As a clinician I see a lot of women with breast cancer and people with other tumors as well, and from day one I tell them that if they have symptoms or problems they have to call me because it is important.  Sometimes patients are afraid.  They think that if they start complaining about this problem or that problem, that 1. The doctor is going to give up on them or  2.  Their doctor is going to think they are difficult. Really none of those things are true.  We have gone through this process with many patients so none of this is unexpected.  It is part of the process, and we all just want to make it as easy as possible.

Chu
I guess the key is communication and education with patients.

Miller
It is.  The other thing I think that has changed over the past 20 years since I finished my

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fellowship, is a greater commitment in medicine, in general, to communication. There is a broader sense of a healthy impact on someone's life and we want people to be cured of these diseases if possible.  We want to cure cancer whenever we can, but we also want people to have the good quality of life they deserve.

Chu
One area that I think we may not do as good a job as we could relates to dealing with the emotional, psychological aspects. Obviously whenever anyone is diagnosed with cancer, or is undergoing treatment, there is always this kind of underlying fear or anxiety of what is going to happen.

Miller
Sure.

Chu
How do you deal with those issues?

Miller
Sometimes the fear of recurrence, and not to get complicated, is inversely proportional to the risk.  Sometimes patients, who have a very, very, small risk of recurrence, have the most worry and anxiety, and that can change their quality of life. Fear of recurrence is one of the big problems that people face. But Ed you are absolutely right, when people first get the diagnosis they are afraid what the future will hold.  I personally address that.  As you know, to share a story, my wife had leukemia years ago so we have been through that journey of not knowing what the future will hold. After treatment, when Joan had a bruise on her leg we would think, what is going on?  Is it the cancer again?  Those are life altering.  There is also what I would call posttraumatic growth.  People go on, my wife, and my patients, go on to do some pretty amazing things after the cancer experience.

Chu
It helps to reprioritize, or refocus, one's view of the world.

Miller
We go through life, most of the time, wanting a sense of control over what happens on any given day; have a sense of order.  Then all of a sudden you're faced with cancer and that sense of order and control are gone.  One day your doctor calls and says they found a cancer.  People do have the opportunity after the cancer experience to rebuild that sense of confidence and maybe even a greater sense of joy in everyday living.

Chu
Obviously the immediate family and close friends play a key role in being the supportive care team, if you will, for the individual patient.

Miller
I am glad you bring that up. The definition of a cancer survivor from the National Cancer Institute is a very interesting one.  It is patients diagnosed with cancer from the moment of diagnosis for as long as they live, which obviously we hope is for years, but the family members and the caregivers are also included in that definition.

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Chu
If you take the strict definition of a cancer survivor, there are 11 to 12 million individuals in the country, but if you take the broad definition, which you just gave that encompasses three-quarters of everyone here in United States, it is a staggering number of people.

Miller
There are some important implications about using this broad definition.  For example, let's take a woman who has breast cancer.  Her family members are considered cancer survivors using that definition, which is valid because of some of the psychosocial issues that children of cancer survivors face, but there are also medical implications.  A daughter of a woman with breast cancer should have better screening than average for breast cancer.  People with colon cancer; their family members also need better surveillance perhaps than average.  There are some good things about the definition that help us keep other people, the rest of the family, healthy.

Chu
It also highlights that cancer basically touches everyone, touches every life, and we have to be aware of the issues associated with the disease.

Miller
When I speak to audiences in the community I ask who there has either had cancer, or had someone in their own family with cancer, and almost everybody raises their hand.  It is a scary diagnosis, but as I tell my patients, and the listening audience now, cancer is a broad term that includes very early stage cancer as well as very advanced stage cancer. The success rate in treating people with cancer is significantly higher than it was and God willing, that is going to continue.

Chu
We have an e-mail from Susan who was treated with a number of chemotherapy agents for breast cancer and now is complaining of numbness and tingling in her hands and feet. She poses the question, "Is there anything that can be done to try and relieve those neurologic symptoms?"

Miller
Good question, and a very common one.  A lot of our patients with breast cancer receive a drug called Taxol, or Taxotere, which commonly causes neuropathy, so what you are experiencing is pretty common.  Fortunately, it tends to improve over time, anywhere from 6 months to 18 months you may continue to see improvement.  I always encourage people to take vitamin B6 at 50 mg a day and a small number of patients notice significant improvement over time.  There are some other medications too, one is called gabapentin or Neurontin, and one is called Lyrica.  These may be of benefit as well. In terms of supportive care issues, be careful.  Make sure you do not get bruises or cuts, almost like someone with diabetes; you want to be careful about that kind of thing as well.  I think it is going to improve though. 

Chu
We would like to remind you to e-mail your questions to canceranswers@yale.edu or call 1-888-234-4YCC.  We are going to take a short break for a medical minute.  Please stay tuned to learn more information about pain management and supportive care with our special guest Dr. Ken Miller.

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   The American Cancer Society estimates that in 2007, there were over 62,000 new cases of melanoma in this country and about 2400 patients are diagnosed annually here in Connecticut alone.  While melanoma accounts for only about 4% of skin cancer cases, it causes the most skin cancer deaths, and when detected early, melanoma is easily treatable and highly curable.  Clinical trials are currently underway at federally designated comprehensive cancer centers such as the one at Yale to test new innovative treatments for melanoma.  The patients enrolled in these trials are given access to newly available medicines which have not yet been approved by the Food and Drug Administration.  This has been a medical minute and you will find more information at www.yalecancercenter.org.  You are listening to the WNPR Health Forum from Connecticut Public Radio.

Chu
Welcome back to Yale Cancer Center Answers.  This is Dr. Chu and I am pleased to be here with my co-host and special guest Dr. Ken Miller who is an expert in the treatment of pain management, supportive care, and survivorship. Ken, let's discuss what the different types of pain our cancer patients may experience are.

Miller
I like to ask patients not just the intensity of pain, but also how they would describe it;  when people say a burning pain, a searing pain or a sharp pain, that actually gives us some hints as to the type of pain. Essentially, there are a few categories. One is called somatic pain.  Somatic pain is where there is injury to a tissue, such as when you hit your finger with a hammer.  It could be a cancer-related pain as well.  Those typically are pretty well localized.  Someone will say they have a pain in their arm or rib. There is something else we call visceral pain. It is usually down deep in the abdomen or the chest and a little harder to describe for people because there are less nerve endings there.  The other thing about pain is a good pain history. The pattern of pain is useful in terms of figuring out the mechanism; is it constant? Is it intermittent? Is it worse in the morning or at night? Those are all part of a good pain history.

Chu
What can be used to help reduce or limit the pain symptoms?

Miller
In a sense, by taking a good history and identifying the character of the pain, that could tell the degree of the pain intensity. The other thing we ask people is what helps alleviate the pain or what exacerbates the pain and makes it worse.  For example, a patient might say, "Using a heating pad works well," so we would obviously encourage that. There are many strategies for dealing with pain.  Some of them are pharmacologic, using medications; that could be Tylenol, that might be anti-inflammatories, steroids, or opioid drugs.  We call it a stepladder approach to pain management starting at the lowest amount of medication and then working our way up.

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Chu
Many patients I see worry that if we start them on pain medication they may become addicted, is that a truth or a myth?

Miller
I am glad you asked that.  That is a myth.  But I have to tell you the myth is still out there, even among doctors. Recently a surgeon said to me, "How can you give Ms. Jones that amount of medicine, when she has her surgery we will never be able to control her pain."  That is not true.  We have plenty of different medications and a wide span in terms of the amount of medication we can use.  For example, we cannot use unlimited rounds of Tylenol because that is bad for the liver or their kidneys, but we can increase the dose of morphine or oxycodone, or a medicine called Dilaudid, because we are able to control pain, we just have to find the right dose.

Chu
I guess the key take home message is that we really do have effective medications to control pain and the key is to maintain an improved quality of life.

Miller
Absolutely.  There is absolutely no benefit to pain.  Again, sometimes patients are afraid of bringing it up for a variety of reasons, but I tell people there is no benefit to pain.  It is demoralizing and dramatically takes away from quality of life.

Chu
Another perception that I think we touched upon earlier in the first segment of the show, is that cancer patients who are receiving pain medications sometimes believe they are at the terminal phase, close to death.  Is that a truth or myth?

Miller
That is a myth but also a very common one.  Pain is very common, and there are a whole variety of reasons for pain including a ruptured disk, orthopedic problems or joint problems. So when we ask patients who are being treated for cancer if they have pain, most people have more than one pain.  In fact, the average is 2 to 3 areas of pain. Often 1 or 2 of those are benign pains, and why live with that if it can be treated effectively.

Chu
Ken, you are the director of the Connecticut Challenge Survivorship Clinic and Survivorship Program here at the Yale Cancer Center, a program that we are very proud of. We have talked about this on previous shows, but for our listeners, could you explain briefly what this clinic and program is all about?

Miller
Yale has had a strong commitment to taking care of people through the cancer experience and beyond it. Being a healthy survivor of cancer is obviously very important, not just getting through it, but remaining healthy. Our program, the Connecticut Challenge Survivorship Program, focuses not just on managing symptoms, but also on the role of nutrition, reducing the risk of recurrence, the role of exercise, promoting good health, and reducing the risk of other cancers developing.  We have people see a nutritionist, a physical therapist and a social worker to give them a chance to talk about the experience of having had cancer. Usually they will then see an advance practice nurse, or myself, to focus on some of the medical issues as well.

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Chu

Who can access this clinic?

Miller
We encourage anyone throughout the Northeast who has had cancer and would like to be seen to call the Yale Cancer Center.  You will come for a whole afternoon and see each of those people on the team, and then hopefully leave with a lot of new information and with energy to make some lifestyle changes.

Chu
You recently organized and shared a symposium focusing on survivorship issues, can you let our listeners know what that was all about.

Miller
In May, we had our first course on cancer survivorship for clinicians.  There are 3 parts. First we talk about psychosocial issues such as fear of recurrence, family issues, intimacy and sexuality.  The second part is on epidemiologic issues such as risk of second cancers, role of exercise and role of nutrition. The last part deals with medical issues such as lung, kidney and heart problems.  That information will all be available for the clinicians as a course on cancer survivorship.  It is about a 12-hour set of DVDs, where we interviewed every single speaker and talked on a patient's level talking about issues of nutrition and exercise and lung problems, etc., on a level where everyone will understand it and can learn about survivorship.

Chu
Out of that experience and symposium, I understand you also are in the process of authoring a book.  Is that correct?

Miller
Absolutely, we have a book that is going to be published about a year from now where essentially 4 clinicians talk about all the issues in survivorship. It is going to be a nice addition to the library that clinicians have as they start seeing cancer survivors.

Chu
We will look forward to reading it in the near future.  What type of research programs are ongoing here at the Yale Cancer Center focusing on supportive care and survivorship issues?

Miller
One of the things that we're hopeful to start very soon is the study looking at nausea and trying to have better control of that symptom for the small number of people who still have problems.  The other studies we are doing are in survivorship.  We are looking at patients who come to the survivorship program and seeing what impact it has.  Specifically, are they making changes in diet and exercise, is there some change in quality of life having participated in a survivorship program?

Chu
You are also involved in the Julie Nielsen project.  Can you tell our listeners what that project involves?

Miller
Sure, this is a wonderful program sponsored through the Department of Social Work at Yale, trying to promote the use of alternative therapies and art. Patients have the opportunity to have a massage or look at some of the other alternative therapies that are available

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such as Reiki and meditation, because we think those things are important as well.

Chu
Another very important initiative that you started when you came on board here at Yale was to develop the Schwartz Rounds.

Miller
The Schwartz Rounds is now a national program at about 120 hospitals.  I think we were the first, or close to the first in Connecticut, but the doctors, nurses, social workers and chaplains get together each month and talk about a patient that is having difficult issues or problems.  It could be a patient where the family moved out or a patient where the family literally moved into the hospital room. The purpose is to build a team and a team feeling, and also for all of us to learn that these are difficult issues and help each other come up with strategies to provide compassionate care.

Chu
That is very important because sometimes the health caregivers do not get a chance to really discuss what their thoughts are, what their emotions are, and what difficult issues they are dealing with.

Miller
It is very challenging and very exciting, in terms of taking care of people with cancer and their families. It is nice to be able to discuss that openly and learn other care providers feelings about it and also their strategies.

Chu
We are near the end of our show.  Are there any other initiatives that you are focusing your efforts on?

Miller
I am very excited that at the end of this month the book that I edited called, Choices in Breast Cancer Treatments is going to be available.  There is a lot of medical information, but most of it is patients telling their own stories. These are women who have all had breast cancer, or are at high risk, and are sharing how they have gone through the experience.  I am also working on a collection of stories that I am going to call Seasons of Survivorship. It deals with what the survivorship experience is like at the time of diagnosis, a year later, 5 years later and 10 and 20 years later. If people are interested in contributing their stories or insights, we would love to hear from them.

Chu
We look forward to reading those 2 books as well.  As always Ken, it is great having you and talking about the issues of supportive care and survivorship.

Miller
It is nice to be a guest on this show.

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Chu
We look forward to having you on a future show.  Until next week, this is Dr. Ed Chu from the Yale Cancer Center wishing you a safe and healthy week.

If you have questions, comments or would like to subscribe to our Podcast, go to www.yalecancercenter.org where you will also find transcripts of past broadcasts in written form.  Next week, we will examine symptom management for cancer patients.

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