Managing the Side Effects of Cancer Treatment with Palliative Medicine

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Dr. Scott Steele, colorectal surgeon, the president at Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to welcome our expert, Dr. Renato Samala, who's a physician within the Department of Palliative and Supportive Care here at the Cleveland Clinic. Renato, welcome to Butts & Guts.

Dr. Renato Samala: Thank you, Dr. Steele. I'm so honored to be here and I'm so excited to tell our listeners about what I do, what we as a department do, and how we can help.

Dr. Scott Steele: That's fantastic. And so today we're going to talk a little bit about managing the side effects of cancer treatment. But before we get into that, tell us a little bit about your background for our listeners, where are you from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Renato Samala: Of course. I was born and raised in Manila, Philippines. I received both my undergraduate and my medical degrees from the University of the Philippines and then moved on to Pittsburgh where I did my residency in internal medicine at the University of Pittsburgh and then completed fellowships in geriatrics and palliative medicine here at Cleveland Clinic. So, I currently practice palliative medicine here at the Main Campus. I see patients in the hospital and then also in clinic at the Cancer Center. Most of my practice revolves around taking care of patients while they receive treatment for cancer. And in line with the podcast's fantastic title, what I do is I treat poops and pukes and “ouchies” and “grouchies.”

Dr. Scott Steele: That's fantastic. And we very much appreciate all the work you do for our patients. And so today we're going to be talking about palliative medicine and how to manage the side effects of cancer treatment. So, to start, can you share at a high level what palliative medicine is?

Dr. Renato Samala: Yeah, absolutely. So palliative medicine is part of palliative care. Palliative care in turn is a model of care that focuses on patients suffering from serious illness, be it cancer, advanced heart disease, end stage renal disease, and many more. And what we basically do is we treat and assess symptoms caused by both disease and its treatment, coordinate care between patients, their caregivers, and their medical team, provide support and resources every step of the journey from diagnosis to end of life. So, the ultimate goal is maximizing quality of life for everyone in that journey. And one of the best things about palliative care is its team approach in caring for patients. Care is provided by professionals from different health disciplines. And so, the medical component or medical specialty within the palliative care team, that's palliative medicine. And then there's also palliative social work and palliative nursing, et cetera.

Dr. Scott Steele: So, digging a little bit deeper there, is palliative care the same as end-of-life care?

Dr. Renato Samala: Palliative care is not synonymous with end-of-life care, rather end-of-life care is part of palliative care. That's another thing that makes what I do for a living quite special. I have the privilege of taking care of patients from the time that they get diagnosed with a serious life-threatening disease such as cancer while they go through treatment and as they get further along the course when cure is no longer an option. I make sure that they're as comfortable as can be in every step of the way.

Dr. Scott Steele: Is palliative care only symptom relief?

Dr. Renato Samala: It's symptom relief plus many more. I also provide emotional and social support. Help patients and families prepare for the latter stages of disease, bridge patients, families, and their medical team through family meetings and help them through tough choices. In other words, we cross that bridge together when we get there.

Dr. Scott Steele: So, when it comes to cancer and chemotherapy treatment specifically, what are some of the side effects that a patient can expect?

Dr. Renato Samala: Well, let me offer some general concepts, Scott, treatment related side effects, especially the ones that involve the digestive system, they're most likely going to happen. I am going to give you a list of side effects and patients will likely get any one of these or a combination of these and it can be quite debilitating and distressing for everybody, especially the patient. And when this happens, it also might prompt the cancer doctor or oncologist to either reduce the dose of chemotherapy or whatever treatment they're getting, take pause on the treatment or stop the treatment altogether. That's the bad news. The good news is that these side effects can be expected, they can be anticipated, and they can be effectively managed. And so, with that being said, while preparing for this podcast, I've been trying to lay out these side effects in as organized a fashion as I can.

And I thought of going from top to bottom, from mouth to butt, just for the sake of our listeners. So, some of the side effects that might involve the mouth as patients go through treatment, particularly chemotherapy and radiation might include pain, dry mouth, taste changes, thrush or yeast infection and mouth sores, and then moving down to the throat and the food pipe or esophagus. There can be heartburns, pain and difficulty with swallowing, especially with radiation. And then down to the gut, there's abdominal pain, nausea, vomiting, diarrhea, and constipation. And then down to the nether region or the butt, there can be skin irritation, pain in the anal region, and diarrhea especially with radiation. And then some side effects that might affect the whole body would include appetite loss, fatigue or tiredness, and weight loss.

Dr. Scott Steele: So just focusing in on the digestive side effects of chemo, the nausea, constipation, bloating, lack of appetite that you mentioned, what are some of the ways that you help these patients?

Dr. Renato Samala: There's a ton of ways that we can help. And again, let me premise that by saying that these side effects will probably occur, but then there are ways to treat these and there are ways to make sure that as patients go through treatment, that they have the best quality of life as can be. So, say nausea, for example, chemotherapy radiation, and then the newer kids on the block, immunotherapy, targeted therapy, all of these might cause nausea. But then we have a host of medications that we can try and can start, and we can maintain patients on so that nausea and vomiting are kept to a minimum. Same thing for constipation and diarrhea and all the other side effects I mentioned. So, there are ways to deal with these.

Dr. Scott Steele: So, is there a specific cause for these digestive side effects?

Dr. Renato Samala: Well, the thing about cancer treatment is particularly chemotherapy is they fight cancer by seeking and attacking cells that are rapidly dividing. The sad thing is they're not able to tell between healthy normal cells and cancer cells, and so therefore those healthy normal cells get affected, therefore side effects arise.

Dr. Scott Steele: So, do these side effects end after the cancer treatment has ended?

Dr. Renato Samala: Yes. For a lot of these side effects, they do such as appetite loss, mouth sores, constipation, diarrhea, nausea. That's why cancer doctors might decide to reduce the dose of treatment or suggest treatment breaks or holidays.

Dr. Scott Steele: So, truth or myth, palliative care physicians are only available to treat pain.

Dr. Renato Samala: That's a myth, Scott. We see ourselves not as merely one trick ponies. We do many, many more things. We offer many, many more services than treating pain.

Dr. Scott Steele: So, can you tell me a little bit about the benefits of this relationship or seeing a palliative care physician for a patient that's going through cancer treatment?

Dr. Renato Samala: Well, the three biggest words are quality of life. That's our focus, that's our priority. So we do that by managing symptoms as optimally as possible by helping patients and their family members prepare for when the disease reaches its advanced stages, a process called advanced care planning. And simply put, we are there for them. We serve as the lifeline for patients and family members as they go through this tough journey.

Dr. Scott Steele: Is palliative care process here at the Cleveland Clinic a standard part of chemotherapy radiation therapy or is there a right time for someone with cancer or a life-altering illness to reach out to palliative care?

Dr. Renato Samala: It's not quite standard yet such that when a patient gets diagnosed with cancer, we are not automatically consulted or asked to get involved. I'm typically asked by my colleagues from oncology or radiation oncology or even surgery to get involved when symptoms become distressing enough that quality of life is affected. So uncontrolled symptoms such as pain, nausea, tiredness, appetite, loss, these are the common reasons for patients to see me in clinic.

Dr. Scott Steele: So, can you tell me about any advancements on the horizon regarding palliative medicine or the care of patients going through cancer treatment?

Dr. Renato Samala: Sure. There are a few new drugs. There are a few new drugs for constipation and nausea and pain management as well that we have in our toolbox. And then studies have also been emerging as to when the right timing is for palliative care to be involved. And then there's this fancy gizmo that we started using a couple of years ago. It's called scrambler therapy, which is a procedure that we offer to patients with debilitating neuropathy or nerve pain or tingling or numbness frequently caused by chemotherapy.

Dr. Scott Steele: How does that work?

Dr. Renato Samala: Some people think of it as a TENS unit, but it doesn't quite work like a TENS unit in that a TENS unit blocks the transmission of pain from its source up to the brain. The scrambler therapy machine, what it does is it scrambles those signals coming from deranged, abnormal, damaged nerves as it goes up to the brain, thereby scrambling those signals such as when they reach the brain, they're perceived or noticed by the brain as non-pain signals. So it's a treatment consisting of electrodes that we place close to where the source of pain is. And it's a series of 10 consecutive treatments but lasting about one hour each time.

Dr. Scott Steele: Very interesting. So now it's time for our quick hitters. It's a chance to get to know our expert a little bit better. So first of all, what was your first car?

Dr. Renato Samala: Here in the United States, it was a Honda Civic, the standard car for residents.

Dr. Scott Steele: What is your favorite sport to watch or to play?

Dr. Renato Samala: Oh, definitely basketball.

Dr. Scott Steele: For sure.

Dr. Renato Samala: I'm a big NBA fan, so I'm so fortunate that we do have a team and a darn good one here in Cleveland.

Dr. Scott Steele: That's fantastic. And so tell me about a trip that you would like to take or something on your bucket list.

Dr. Renato Samala: Oh, sure. I'm actually going to take this trip, so I'm going home to Philippines, but then me and my family, we're also going to take side trips to Tokyo and Singapore, places where I've never been.

Dr. Scott Steele: That's absolutely fantastic. And if you could go back maybe to the end of high school or college and give yourself a piece of advice, what would that be?

Dr. Renato Samala: Do what floats your boat. Yeah. Don't be influenced by what other people say. Just do what floats your boat.

Dr. Scott Steele: That's fantastic. And so, give us a final take home message to our listeners about this managing the side effects of cancer treatment.

Dr. Renato Samala: For most, maybe all patients with cancer, this is the biggest, hardest fight of their lives. Let us be in your corner. Let me and my team be in your corner. Adequate control of symptoms and having all the resources in place for family members and caregivers can only mean continuous treatment, less treatment disruption, and perhaps a better chance at winning the fight, and most importantly, getting the best quality of life.

Dr. Scott Steele: That's fantastic. And so, to learn more about palliative and supportive care here at the Cleveland Clinic or to schedule an appointment, please call the Cancer Answer line at 844.891.7086. That's 844.891.7086. You can also visit our website at clevelandclinic.org/palliative, that's clevelandclinic.org/palliative, P-A-L-L-I-A-T-I-V-E. Dr. Samala, thanks so much for joining us on Butts & Guts.

Dr. Renato Samala: It's definitely a pleasure, Scott.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.