DR LOVE: Another area that we gathered some information on that I was curious what your thoughts were had to do with other, let’s say, complementary or supplementary issues in the management of these patients. One was the use, self, of complementary therapies, including palliative care, which, of course, so much has been done at your place, as well as psychologic counseling. I was hoping it would have been more. How about in your own practice?

DR BIRRER: I would think the participation rate in that part of the questionnaire is going to be somewhat institution dependent. And what I mean by that is, for instance, at Mass General, given the size and the nature of the institution, many of the complementary services that you listed there are actually provided within the cancer center. They’re available during the infusion, in the infusion center. And of course many of them are actually free. And so our participation rate would be, in general, higher than what was listed there.

As you know, palliative care, based on Jen Temel’s paper in New England Journal brought palliative care right up front for non-small cell lung cancer. We’re not quite that aggressive in ovary. But I would say a substantial percentage of our platinum-sensitive recurrence and essentially all of our platinum-resistant recurrence will end up seeing palliative care. We plug them in early both for pain management and — a lot of ovary patients have significant GI symptoms, nausea and vomiting. And they help manage that.

The other component, I think, that’s unique about ovary, when you talk about psychosocial or psychological counseling, you probably should dovetail into that the clinical geneticists for the ovary patients. Because when they have a BRCA1 or 2 mutation or they go for testing, they’ll go to the clinical geneticists. The clinical geneticist then will spend a lot of time counseling, may even bring in a psychologist both for the patient and the family.

DR LOVE: Whenever I talk to somebody from MGH, I always like to ask about palliative care because I’ve been so intrigued. And we’ve of course talked to Jennifer Temel. But the thing that intrigues me, that I like to ask people about, is the issue of what does palliative care offer a patient who’s not really symptomatic? Because in this model, you have a diagnosis of advanced ovarian cancer, for example, even if you were asymptomatic — the idea is, they could benefit from the palliative care person. I understand symptoms: Okay, maybe they manage them better. But when they’re not symptomatic, what do you think it is that the palliative care people are providing that the patients value?

DR BIRRER: I think there’re two components to that. One is symptom to control. And of course I would never say I don’t believe my patients, but one of the elements that have come out of Jennifer’s work and even some that we’ve done in ovary, in ovarian work, is, when you plug in palliative care, you actually find out that even though the patient reported being asymptomatic, that there’s more going on than just that, symptoms that they consider to be perhaps their baseline, maybe a little worse, but something that they’ve had for a long time.

I had a patient who had pretty bad reflux throughout her medical history. She developed ovarian cancer, and she was having significant reflux symptoms without reporting it because she thought that that was, in fact, her baseline, when, in fact, substantial amount of tumor wrapped around the bowel, around the stomach was clearly aggravating it. So I think the palliative care input on that level is very important, to elicit what the real status of symptoms are for the patient and then guide them through interventions.

The second issue is much more almost mystical. I think that there is a psychological value to palliative care, the palliative care effort. And I actually distinguish that from having a, actually, board-certified psychiatrist come in, or psychologist come in and see the patient. It’s a different approach. And I think Jennifer’s report in New England Journal touched on that, which is, whether it’s comfort and having the patient appreciate that they’re not alone in this disease — and of course we as treating physicians will do that, too. But I think the palliative care people have a particular niche there.

Does that lower stress hormones, increase endorphins, and that, in fact, is important for the effects of chemo and survival? That needs to be worked out, but I think there’s a component of that.

Metastatic wild-type nonsquamous non-small cell lung cancer (NSCLC)

Metastatic colorectal cancer (mCRC)

Metastatic epithelial ovarian cancer (OC)