Twice a month I staff our outpatient facility at the cancer center, mostly venous access procedures, biopsies, and paracentesis. Assigning a full professor to staff this area is economic madness, but as I discussed in a previous column (see What is an IO Practice?, September 24), such entry-level IO procedures are points of contact with patients and referring physicians, providing opportunities for free, unsolicited IO consultation. This allows you to disseminate information about IO procedures that may benefit the patient in ways that they and their doctors may be unaware of or have overlooked.
One of the patients who came in for a chest port was heavily narcotized. She suffered both from inadequately controlled pain and the complications of chronic narcotic therapy, including depressed mental status and constipation. These in turn contributed to her deteriorating performance status, anorexia, and weight loss. Her quality of life was terrible. I reviewed her history and diagnostic imaging and discovered that she had an unresectable locally invasive renal cell carcinoma causing her pain. She had undergone a series of futile systemic therapies which added toxicity but no response. The literature on palliative embolization of renal cell carcinoma dates back to the 1970’s, with pain control achieved in about 90% of patients, yet her young medical oncologist was completely unaware of this option. All it took was an email to generate a formal IO clinic consultation.
That single point of contact is just the tip of the iceberg. If her oncologist was unaware of palliative embolization, how deep is the level of ignorance among all the GU oncologists? What about the Palliative Care and Pain Medicine services, who also have a role in the care of these patients? This single case led to invitations to present at GU Tumor Board, Palliative Care Rounds, and the Pain Management Lecture Series, spreading the gospel of IO.
90% of cancer patients suffer from uncontrolled pain at some point in their disease – it’s what they fear most. Relief from pain will earn you more gratitude than treating the cancer. You may be the source of that pain -- IO procedures can inflict considerable pain. Opioid and non-opioid pain management, including bowel regimens, is a critical skill for the interventional oncologist. Palliative care and pain management specialists are useful in difficult situations, but most routine cases of pain can be managed without subspecialty referral. This requires knowledge of the different narcotic and non-narcotic drugs, their relative potencies, side effects and synergies. You should be able to prescribe appropriate doses of continuous release and short-acting narcotics, concurrent bowel regimens, and understand how to integrate non-steroidal anti-inflammatory drugs and non-narcotic pain medications such as gabapentin.
The unique contribution of interventional oncology to pain management is minimally-invasive image-guided therapies such as embolization, ablation, and neurolysis. These provide substantial relief from pain and narcotic dependence and offer tremendous improvements in quality of life. Countless patients are out there suffering needlessly for lack of referral to an IO. Ablation is better than XRT for focal bone pain. Nerve blocks are 5-10 minute procedures for the trained interventionalist. Embolization takes away capsular pain overnight. Pain management is one of the unmet challenges in growing IO as the fourth pillar of cancer care. Tell WCIO what you need to be able to offer these services in your practice. Remember, they can always hurt more -- it’s our job to make it hurt less.