Transcript
WEBVTT
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I remember I used to have to do bone marrow tests, you know, I was a hematologist, so I used to have to do that.
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And I would use hypnosis and the fellows would say they were smelling cider donuts and hearing the crackling of the leaves and the light coming through it every time they did a from then on, because We would take a walk in the woods in the fall, you know,
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I'm Dr Tina Kaczor
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and I'm Dr Leah Sherman
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And we're two naturopathic doctors who practice integrative cancer care
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But we're not your doctors
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This is for education entertainment and informational purposes only
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do not apply any of this information without first speaking to your doctor
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The views and opinions expressed on this podcast by the hosts and their guests are solely their own
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Welcome to the cancer pod Hi, this is Leah from the Cancer Pod.
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Now, let's get to today's episode.
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Tina and I had the opportunity to speak with Dr.
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Janet Abram, an internationally renowned expert in palliative and supportive care.
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Dr.
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Abram is an institute physician at the Dana Farber Cancer Institute and a distinguished professor of medicine at Harvard Medical School.
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She combines her background as a former practicing oncologist with her passion for supportive care.
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She's the author of Comprehensive Guide to Supportive and Palliative Care for Patients with Cancer, the definitive resource for physicians about cancer support, palliative care, and pain management.
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Most recently, Dr.
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Abram was awarded the prestigious Walther Cancer Foundation Award from the American Society of Clinical Oncology, recognizing her significant contributions to palliative and supportive oncology care.
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You We were so thrilled to have her on the podcast to share insights and expertise.
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welcome Dr.
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Abram.
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Thank you.
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Yes, thank you so much for taking some time out of your schedule to come talk to us and our audience about palliative care.
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Very happy to be here.
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Nowadays, um, some of the oncology practices are calling it supportive care, which is fine with me too.
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I did oncology for about 20 years.
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And so I have a real sense of, of the supportive, if you will, and palliative needs.
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And if people Conflate palliative with end of life and hospice.
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We don't want that.
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So if supportive is more helpful to understand that we offer services from diagnosis of a serious illness like cancer on, that terminology is fine with me too.
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I think that's the most important thing is that patients when they hear palliative, they think end of life.
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And so, yeah, I mean, if, if there are other ways that you could, define for us what palliative care Slash supportive care entails,
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Sure.
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Sure.
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I think the best way to explain it is that.
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We are there to partner with, and I'll say the oncologist, because that's, that's the group I know the best.
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We're there to partner with the oncologist to make, the patient and family's quality of life the best that it can be.
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Uh, some people cause an extra layer of support, but when I introduce myself to a patient or family, I say, Your team has asked me to see you because you have problems, I'm told, with some of your symptoms or you have some questions you wanted to talk about.
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How can I help?
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So I don't go into a big description of what palliative care is.
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I just try to be what it is.
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Yeah, it's interesting that we start with this because I can tell you, I'm overseeing some coursework in integrative oncology right now, and it's a fellowship for people who are already professionals, and we have a palliative care segment, and I would say at least 40%, 4 out of 10 of the, of the, Fellows.
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Conflated hospice care and palliative care.
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And I know that that's true for the public as well, but I was a little surprised that it was also true for professionals.
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So, I think this is important, because the word palliative does sound a little bit, it is conflated with hospice more often than not, and people are reticent.
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So, the fact that you came up right out of the gates telling us there's another term called supportive care, I like that.
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I like that.
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Dr.
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Pereira did some studies down in MD Anderson and found that if he called his team supportive in palliative care, then he got earlier referrals.
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And so our, our new book.
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It's called Comprehensive Supportive and Palliative Care for Patients with Cancer, a guide, you
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Yeah.
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It's hard, there's, supportive can also just mean antibiotics and transfusions and what we're doing is so much broader than that.
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is it fair to say that is addressing symptoms of people who are not looking at a curative treatment?
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Would that be accurate?
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So again, I would say that palliative care can be life saving and can enable a cure.
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So palliative care is there for the symptoms of people who are undergoing cancer treatment.
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Or not, but undergoing curative or palliative, if you will, cancer treatments.
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And we're also there for the communication challenges because often a patient or family member doesn't want to question the oncologist.
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They don't want to show lack of faith.
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They want to be grateful.
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And yet as The course continues.
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Sometimes there are turnoffs and you're not sure what the risk benefit or let's say the burden benefit of a given treatment would be for you if your disease is more far advanced.
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So we're often there as the people you can talk to about this and we can help you sort out your goals.
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Uh, what your hopes are, what your worries are, and then match those because we'll ask the oncologist, what are your hopes for this treatment?
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What are your worries for this treatment?
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So we can match the hopes and worries of the two parties, in a very supportive and, and respectful way to say, gee, I, I hear what you're saying that you hope this treatment will do.
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The oncologist isn't really sure that it will do that, but it could do this.
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Would that be okay?
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So in a way, we're translators, maybe, interpreters of The medical ease, uh, you, you often have only 15 minutes or so with your oncologist and you want to talk about the treatment.
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You don't always want to talk about your symptom or your worries, because maybe you want to get an experimental treatment.
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And if you show that you're not with it and for it, you'll kind of fall down on a list a little bit of the people who get the experimental treatment.
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That's.
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The projection of the patients, that's not how oncologists think, but my, even my own patients used to think that way, and sometimes the, um, the doctors who were caring for my patient in the hospital would have to tell me that the patient was done, and I would say, but they never told me that.
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And they said, Oh, they wouldn't want to disappoint you.
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You have tried so hard and they're so grateful to you.
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They would never want to let you down.
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Now, I can't believe I'm the only oncologist that's happening to, you know, so I would say it's not just for people who are not going to be cured of their cancer.
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We have enabled people to be cured of their cancer by dealing with their symptoms from the treatment.
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And the cancer, so they could get through curative treatments, those who have that available to them.
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I hope that's helpful.
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Yeah, what you're describing is almost like a navigator, or what we dream a navigator would be, which is to help bridge that, expanse of both options and communication and be an impartial party of sorts to say, okay, let's see where you're at and make sure that the patient as an individual is served.
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That's what we're really good at.
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Yeah, we're, we're trying to really explore with patients and families what they're hoping for, and then, as I often say, and what else, and what else, and what else.
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Because everybody has layers of what they're hoping for in cancer treatment, right?
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And so we try to unpack that so that we can help the patient have a realistic, as much as they can tolerate, a realistic understanding of what's going to be entailed.
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And, I think we really do try to partner with the oncology team because we have more time to unwrap all these things, to be culturally sensitive, to explore As I said, things that the family and patient might not want to bother, if you will, the oncologist with in the time they have together.
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I think we've all had the experience where there are patients.
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And perhaps it is due to cultural differences where they will, they will say to the oncologist what they think the oncologist wants.
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To hear, and I know from my own experience with my mother who went through palliative care, um, she was able to speak with the palliative care doctor on a different level,
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Oh, good.
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I'm so
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because she had such, she had such a, um, I don't know.
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I mean, she loved her oncologist, but sitting in appointments with her, she wasn't quite, you know, As forthcoming as I knew, I'm the one answering her questions, you know, like, that's not true.
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And so I feel like she had, she had a much, uh, different relationship with her palliative care doctor.
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And yeah, that whole experience was, it was so important.
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They helped to clarify different aspects of her treatment and goals, like you were saying, it really, um, Yeah.
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I have, I have a lot of respect for palliative care.
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Thank you.
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Well, and saying that palliative care is appropriate, even for people who are looking to be cured is actually news to me.
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I honestly always think of palliative care as living with a condition comfortably and with, you know, no pain and no symptoms, right?
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Like symptom control while you have an underlying condition, whatever that is, whether it's cancer or a heart condition or whatever, but palliation of symptoms while you live out your life rather than Being on a curative course, where possibly you won't be having that condition anymore in the future.
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I mean, that's actually a twist for me because I have always thought of palliative care as symptom management.
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that because a lot of the palliative care came up from the end of life aspect.
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When we first started our field, which was only less than 20 years ago, 2006, we became a subspecialty of internal medicine.
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At that point, very few oncologists were actually part of that initial core of people who started palliative care.
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But those of us who were oncologists understood from having tried to get our patients through treatments, which were a lot harder in those days than some of the treatments are now, they couldn't get through them without really, really good symptom management, but also an understanding of the psychological toll, you know, the trauma that medical treatment induces.
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in everybody, the patients, families.
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So we have an understanding of the trauma they're going through.
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We have an understanding of the psychological and spiritual and existential resources they need to get through it.
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And there are many cancers that are curable.
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But the road there is not easy, so having a partner right up front can make all the difference, at least in my clinical experience.
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Of course, by far the most cancer patients are on a palliative, trajectory.
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Nowadays that can mean years and years and years of, Palliation, especially for breast cancer patients, and now other patients, and the idea of cancer being like a chronic disease, like heart failure, as you said, or lung disease or something.
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For many cancers, I think that's true.
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And so you need a partner to help you navigate that too.
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But the very beginning of, of a curative cancer treatment, maybe we should have the metaphor of, of the guide that gets you through the rapids, you know, in the beginning of that, of the, uh, of the boat.
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Sure.
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what we're there for is, is we know where all the rocks are, you know, and we know where the calm place is going to be, and we can encourage you to stick it out with us to get there, you know, I like kind of like white river rafting is a metaphor for some of the beginning of the oncology treatments, even if they're just emotionally and spiritually and existentially very rocky.
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You know, because people blame themselves unnecessarily.
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They look to what they did to have this happen to them.
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And so all of those questions come in the beginning, right?
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Not just the, not just the end.
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So I'm glad that we could clarify, that practice.
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I think that the goal setting aspect is also kind of unusual and in some ways it's delightful.
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I mean, our palliative care doctor helped patients get married,
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Uh huh.
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patients go on a, on a vacation or something, I mean, or had them create a collage or something of like all their grandchildren.
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I mean, there are all of these.
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different aspects that were beyond just the, the symptom, you know, the physical symptom management part.
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And so, um, yeah, that's, that's, that's kind of incredible that there is someone there who's listening.
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and as you know, being naturopath, symptom management is the Maslow's hierarchy is the bottom of that is the key.
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If you're in severe pain, if you're severely depressed, if you can't breathe, you can't do any of those important things.
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So all of us have to be very skilled symptom management, but that's for me, though.
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That's how I started.
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That's the bottom layer.
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That's the, that's That has to be done, but you usually can't do that without addressing the other things too.
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But you do have to be pretty good at using the medications and other techniques, the ones that you employ, to get people at least to a place where their symptoms, what I say is they're not here anymore.
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Maybe they're down here.
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You know they're there, but you can function again.
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Get people back to what their level of function is to start with.
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And then we can start to do the other things.
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it's very important.
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All palliative care doctors.
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And maybe that's why you think of them that way, because we do do magic sometimes with symptoms.
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Uh, nurses certainly have told us that we do.
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Um, they weren't really happy.
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They didn't know quite what we did when we started in 2001 at Dana Farber in the Brigham.
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And then they saw some of the things we could do and they're like, Whoa, okay.
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Now we, now we see we can get the person back.
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But once you have that person back, that's just part one.
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Yeah, yeah, as you're talking I'm thinking about how much this lends itself to integrative medicine and integrative protocols I mean medications absolutely pain management and other symptom management and it's a quality of life.
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We're talking about so there's a lot of things whether it's through nutrition or acupuncture or movement Uh, exercise, all sorts of ways of helping people optimize their health, no matter where they are along that cancer continuum.
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lately exercise and nutrition, exercise especially has been shown to be life prolonging.
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In many cancer patients and, and the amount of exercise that we can induce them to do, even with some advanced, more advanced disease, of course, acupuncture, of course, massage, um, hypnosis, I'm trained in hypnosis and, and I think it just informs my communication with patients and families and doctors.
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and nurses, everybody, because once you're, as you know, once you're trained in hypnosis, the world is a metaphor, sort of
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Is that right?
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No, I don't know that.
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all hypnosis.
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Have you been trained in hypnosis?
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Is it part of your
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No.
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Oh, I'm sorry, Leah.
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No.
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So I was trained in hypnosis back in the day when we had fewer medications.
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And, I learned there's an American society of clinical hypnosis, Only lets clinicians into the courses.
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You have to have a clinical degree like you guys do, or a nurse or a doctor.
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And I learned all about the power of my voice and metaphors and, the ability to take someone where they'd really rather be when we didn't have good meds for nausea and vomiting or pain.
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Hypnosis is very powerful for deliveries that can shorten the first stage of labor, for example.
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It's a very, very wonderful technique for symptom management, but also for ego strengthening.
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I mean, you do what you can do.
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So psychiatrists do it with psychiatry and OB do it with OB.
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I do it with my, my cancer patients.
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But I found it to be very rewarding and it really connects you very closely with your patients when you're doing this.
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You might've heard of guided imagery.
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Which is close to hypnosis, but, but not the same thing.
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But if somebody is in trance, taking them on that guided imagery.
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is more powerful.
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I mean, you bring in all the senses and And I remember I used to have to do bone marrow tests, you know, I was a hematologist, so I used to have to do that.
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And I would use hypnosis and the fellows would say they were smelling cider donuts and hearing the crackling of the leaves and the light coming through it every time they did a from then on, because We would take a walk in the woods in the fall, you know, because that's where the patients one time I went, I started to go to the beach and the patient said, no, no, I want to go for a walk in the woods.
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I know what you're doing.
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So off we went for a walk in the woods and he was, he was distracted and the fellow was calm.
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It's a very wonderful technique that I would very much encourage you to add to your practice.
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If, if you find that interesting.
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Oh, absolutely.
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Absolutely.
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Yeah.
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I do know some of my colleagues do use it, so I'm gonna have to ask them where they got their training now.
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Sure.
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Are there other, more integrative or, I guess, non pharmacologic, pain management tools that you employ with your patients?
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Well, now that we have, we have a more robust Zakem center, which is our integrative therapy group at, at Dana Farber.
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I recommend acupuncture.
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I've, I've read the data and the NCCN recommendations and the things that are, are most recommended.
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So definitely.
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definitely yoga, uh, massage, acupuncture, especially electro acupuncture, which I've had myself for a bad back, which has been life saving, I don't know enough about Qi Gong to recommend it or not, but they do it at the Zakem Center.
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Exercise.
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I mean, I consider education and reassurance a non pharmacologic pain regimen.
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I mean, I had an aunt had breast cancer and had to get a bone scan to see if it was metastasized.
00:19:19.453 --> 00:19:21.794
She had arthritis everywhere.
00:19:22.544 --> 00:19:27.653
So I told her, Your bone scan is going to light up like a Christmas tree, but don't worry about that.
00:19:27.933 --> 00:19:32.074
They're going to want to get x rays of everything, but it's not cancer, it's your arthritis.
00:19:32.074 --> 00:19:32.131
Yes.
00:19:32.519 --> 00:19:36.700
To me, that's education reassurance prevented an awful lot of pain.
00:19:37.390 --> 00:19:54.700
what other, I mean, non pharmacologic, all the counseling techniques, all the meditation techniques, cognitive behavior therapy for insomnia, all of those in, in my book, there's a very large chapter on the non pharmacologic techniques for pain.
00:19:56.130 --> 00:19:59.190
I couldn't treat a patient in pain without, absolutely not.
00:19:59.849 --> 00:20:01.700
What, which ones do you find most useful?
00:20:01.700 --> 00:20:02.859
For I'm curious
00:20:03.460 --> 00:20:06.700
Depending on the patient, I think, I mean, I think exercise is huge.
00:20:07.442 --> 00:20:16.942
Exercise is the thing where, I mean, I think about my patients who are on aromatase inhibitors and I talk to them about, you know, well, what makes, what makes it better?
00:20:16.942 --> 00:20:19.012
And they're like, well, movement makes it better.
00:20:19.323 --> 00:20:23.012
So then I encourage exercise and they're like, well, I can't exercise, I'm in too much pain.
00:20:23.073 --> 00:20:23.813
Oh,
00:20:23.819 --> 00:20:41.134
it's, it's that dance, but, um, I have referred patients to an exercise program at one of the cancer centers where I was working and the patients who stuck with it were just they were amazed because it was it was a it was guided exercise It was designed for them,
00:20:41.733 --> 00:20:42.344
Yeah.
00:20:42.804 --> 00:20:42.993
Yeah.
00:20:42.993 --> 00:20:46.387
And physical therapy, occupational therapy, art therapy, music therapy.
00:20:46.387 --> 00:20:55.773
I may have left something out, but everything that engages the mind and the spirit, which are all part of the body, everything is part of everything.
00:20:55.903 --> 00:20:58.324
I mean, Eric Cassell was my mentor and friend.
00:20:58.334 --> 00:21:02.034
He's passed now, but he used to say suffering is suffering is suffering.
00:21:02.034 --> 00:21:02.354
You don't.
00:21:02.653 --> 00:21:03.394
parse it out.
00:21:03.983 --> 00:21:05.304
The body doesn't parse it out.
00:21:05.483 --> 00:21:14.374
And I feel like whatever the, I tried to find out what the person was doing before they got sick, you know, and what was helpful to them.
00:21:14.614 --> 00:21:19.494
I'm wondering whether the virtual reality, extended reality experiences will be helpful.
00:21:20.355 --> 00:21:26.204
I've seen as it can be wonderful for pain, virtual reality for changing dressings and burn patients.
00:21:26.204 --> 00:21:31.394
For example, you don't need any medication with virtual reality in the studies that have been done.
