Personalized Cancer Care: Power of Doing More or Less

Summary

This conversation explores the concept of doing more or less in cancer treatment and the importance of evidence-based medicine and guidelines. We discuss the need for physicians to keep up with current science. The Choosing Wisely campaign is introduced as a way to de-implement low-value practices. The conversation also highlights the trend of doing less in oncology and the importance of person-centered care. It explores the concepts of precision oncology and personalized healthcare, as well as the importance of partnership and patient engagement in decision-making.

Takeaways

• Physicians need to keep up with current science and guidelines to provide the best care for their patients.
• The Choosing Wisely campaign aims to de-implement low-value practices in oncology.
• There is a trend of doing less in oncology, focusing on precision medicine and personalized healthcare.
• Palliative care plays a crucial role in improving the quality of life for cancer patients.
• Effective communication is essential to avoid the nocebo effect and ensure patient understanding and engagement.
• Partnership and patient engagement are key in providing person-centered care and making shared decisions.

Chapters
00:39 Keeping up with Current Science and Guidelines
01:39 The Emergence of Evidence-Based Medicine
03:02 The Choosing Wisely campaign
05:28 Balancing Doing More and Doing Less
06:51 The Trend of Doing Less in Oncology
08:51 The Importance of Person-Centered Care
09:16 Precision Oncology and Personalized Healthcare
11:07 The Role of Palliative Care
14:23 The Importance of Shared Decision-Making
15:04 Precision Oncology vs Personalized Healthcare
18:13 The Importance of Communication and Avoiding the Nocebo Effect
19:43 The Importance of Palliative Care
24:42 Avoiding the Nocebo Effect in Communication
28:32 The Importance of Partnership and Patient Engagement
32:41 Conclusion

Resources
-ASCO/SIO Pain Management Guidelines
-Choosing Wisely campaign

Check out the book: "Healing and Cancer: A Guide to Whole Person Care"
Visit https://www.healingandcancerbook.com/ for more information.

Connect:
Twitter: @DrWayneJonas
Facebook: Dr. Wayne Jonas
Instagram: @drwaynejonas
LinkedIn: Dr. Wayne Jonas
LinkedIn: Alyssa McManamon

Visit Healing Works Foundation www.healingworksfoundation.org for more information.

Dr. Wayne Jonas is a board-certified physician and Dr. Alyssa McManamon is a triple-board certified hematologist/oncologist. The opinions expressed on this show are those of the hosts and guests and do not necessarily represent the views and opinions of their places of employment, the Department of Veterans Affairs, or the United States government. The opinions expressed on this podcast are meant for entertainment and education and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Wayne Jonas and Dr. Alyssa McManamon have no relevant financial disclosures.

Transcript

Please note that this transcript is produced electronically and may not be an accurate representation of what was said. It may not be reproduced, edited, altered or modified in any way without prior written permission. Any use of quotes or excerpts from this interview requires explicit permission from Healing Works Foundation. Please contact us at healing@healingworksfoundation.org if you would like to use any part of this transcript for quotes or other purposes.

“How Healing Works with Dr. Wayne Jonas & Dr. Alyssa McManamon”

Personalized Cancer Care: Power of Doing Less or More

Wayne Jonas:

Hello, and welcome to the next episode of How Healing Works. I’m Dr. Wayne Jonas.

Alyssa McManamon (00:11.249)

And I'm Dr. Alyssa McManamon. Our focus today is on the concept of the power of doing less. The physician's creed of do no harm in cancer applies as we consider the level of toxicity in the treatments we're prescribing to patients and how it impacts them individually. Strong evidence that comes from quality science is one of the great advances in modern medicine. 

As physicians, part of our job is to keep up with the current science and best practices in medicine. Examining studies with a critical eye, an understanding of the questions that are being asked and answered, who's funding the study, the sample size, and so many other details are important to consider. Also keeping up with current guidelines, such as the ones that ASCO and SIO recently published jointly, will only help us to more effectively treat our patients and help support their individual needs during and beyond cancer treatment.

Wayne Jonas (01:09.704)

I agree. You know, science continues to advance steadily, rapidly, and oncologists need to discuss the advances in oncology with their patients. And this can be challenging when it's a moving field. It happens often that practice lags behind the research. There is good research out there that should be used and it just doesn't get into practice.

But equally what happens is that when people learn something in practice and training, for example, they don't update their practices to the research itself. I'll give you a little bit of context of this. When I taught evidence-based medicine at Walter Reed for many years, when I ran a fellowship there, the Cochrane collaboration and the concept of evidence medicine,

evidence-based medicine was just emerging. And the reason it was emerging is that most clinicians were trained in sort of a hierarchical model where the chief attending, who had decades sometimes of experience, would say this is, in his opinion, the best approach to this particular patient. And the others would sort of follow suit, and that's what you would learn in practice.

Later on, the research would show that perhaps that recommendation was wrong, maybe even harmful. There's many cases of that. And it wasn't really based on data that you can't get out of a single experience or even decades of experience. And you needed to use good science in order to determine what was effective or not effective. And so the area of evidence-based medicine or the application of science at the point of care was born.

And part of what was discovered in that was that not only were we not always keeping up with the science or even paying attention to the science, but sometimes the science was telling us we should not be doing some things. There are some things that not only weren't very helpful, but perhaps were even harmful for patients. And so out of that was born something that we'll talk about here

Wayne Jonas (03:28.76)

that started in general medicine, but also is now being applied in oncology called the Choosing Wisely Campaign. It was launched officially by the American Society of Clinical Oncology in 2012. And Alyssa, as a practicing oncologist, can you talk a little bit about what that is and what kind of impact it is having in oncology?

Alyssa McManamon (03:54.237)

Yeah, sure. As you said, Choosing Wisely in oncology was launched in 2012 and really was some recommendations that were to be evidence-based and to talk about how can we de-implement some lower value practices or low value practices. And so, you know, in 2012, I'm not sure that I was actually aware of it. I'm very aware of it now, but it's interesting. You know, it was covering things such as, you know, are we over-transfusing

patients, for example, who are in-patients without cardiac issues. So are we transfusing people above values of seven to eight if they're otherwise stable? Maybe we don't need to be doing that. Or are we overusing GCSF or white blood cell stimulating agents when there's less than 20% risk of febrile neutropenia from chemotherapy? So for the way it actually showed up in practice was,

since 2012 and as we use the guidelines in following up patients, sometimes we'll see changes, for example, in the surveillance. Sometimes we used to scan people more often than we do now, for example, in the post-treatment surveillance period for different malignancies. So sometimes there'll be changes in the NCCN guidelines related to maybe we were overdoing things, knowing that radiation from CT scans now is kind of more in the forefront of, well, is that safe? Is that something we wanna do if we don't have to do?

Or what's the risk versus benefit. So those conversations come out when you're thinking about Choosing Wisely.

Wayne Jonas (05:28.576)

Now that's great. I think, you know, once things get embedded in practice, sometimes they're hard to change. And I know there's been a number of attempts in general medicine, including in oncology, like PSA screening and that type of thing, to do less in that area. And it's very difficult, even with concerted efforts to educate clinicians, to provide feedback on their behavior, et cetera, et cetera.

The changes in practice are difficult to make. And so it's important that the idea that, instead of just adding things, that you might also want to remove things or do less under certain circumstances, and then maybe add more in some other areas like person-centered or palliative care, might be something you have to step back, look at specifically and say, all right, how can I address that as a practice improvement

project in those areas. We can talk a lot about that in our upcoming book and we talk about that with the oncology leader groups that we've been working with over the last several years. I remember, I mean, I really enjoyed reading the book, The Emperor of All Maladies by Siddhartha Mukherjee.

Wayne Jonas (06:51.96)

And you could almost summarize it by saying oncology has been a series of steadily doing more and more and more, and then reversing that trend and doing less and less and less. The example in surgery is the Halstead surgery, radical mastectomies getting even more and more extensive until they finally realized it wasn't necessary and then reduced so that many people could get away with lumpectomies, for example, eventually and doing less. Same thing in chemotherapy.

Increasing multi-drug approaches in chemotherapy and then a more precision-oriented reduction in chemotherapy in those areas. I know, you know, 30 years ago, we didn't have a way of selecting ER-positive breast cancer patients who were over 60, and you can speak to this, Alyssa, more than I can, but we now have oncotypes or gene

assessments for some of those patients that can say who's going to benefit and who's not going to benefit from chemotherapy. And that has resulted in avoidance of chemotherapy, doing less treatment in those areas. Radiation is the same thing. There's been a steady decrease in the amount of radiation, the type of radiation, the focus of the radiation in those areas. So when it comes to the tumor type and the tumor treatment, I'm sorry, that there is this...

trend of doing more and then doing less, but I think we're in a phase when doing less is important and we notice that people can do well during that and they have less side effects, they have better quality of life, more efficient treatment in those areas. And so that allows us to take care of the person. So do more in terms of taking care of the person, identifying what matters to them and incorporating that into the treatment plan. Would you agree?

Alyssa McManamon (08:51.441)

Yeah, I think it's interesting. It's kind of an embarrassment of riches. As you said, there have been so much advancement within treatment paradigms of what we can do. And now maybe there's some questioning within the research world of, well, what is best? We can do lots of things, and which of these bring the most value? So.

It's interesting the choice of words, Choosing Wisely, because we have this embarrassment of riches from which to choose, and we are trying to navigate with an individual patient what makes sense for their situation. You mentioned kind of the genomic testing for breast cancer, thinking of, it doesn't have to be age 60 per se, but post-menopausal versus pre-menopausal, and we're always differentiating our breast cancer patients based on certain factors, both for the patient and for the tumor.

But the genomic testing can certainly help to determine who may benefit from adjuvant chemotherapy and who may not. And interestingly, like I was mentioning, research is moving toward even using the genomic testing on the breast tumor tissues in ways that can help determine whether or not a postmenopausal woman might benefit from radiotherapy, say, like the IDEA trial that's now five years out.

And so longer study will really help determine who can do less or who can avoid, say, in that case, radiation to the breast. But that's happening in other parts of research as well. So I was just in a meeting where it was being discussed about a prostate cancer study where they're looking at giving five fractions of radiation, SBRT

or radiotherapy to high-risk prostate cancer patients. Alternative in that study would be the standard therapy with radiation of 25 to 30 fractions or whatnot. And so that is a jump from the low-risk setting where five fractions have been offered and looked at to actually now looking at it in the high-risk prostate cancer setting. And I think we are seeing researchers really consider how do we meet patients where they are in terms of what's feasible for people. you know, and what is safe if we can do less. And I think that's a great move.

Wayne Jonas (11:07.828)

Now, I think that's true. I think there's an area where, at least in this podcast and in our upcoming book, we emphasize where it's important to do more. And that's around the care of the person itself. We call the integration of the treatment of the tumor and the attention to what the patient wants, what matters in the patient's life. That integration is whole person care.

And when a person's diagnosed with cancer, they tend to go fully into the tumor treatment component of it, and we neglect even good evidence that we now know is important for quality and even quantity of life when we pay attention to the whole person. And things are emerging now on that area to show that not only does the tumor micro environment in which the cancer is growing get influenced

by our behaviors, by exercise, by the microbiome and the diet, by various kinds of wellness activities like sleep and social support, but also by improving stress management, reducing anxiety and depression, which just on their surface are important to do anyway for an individual that's undergoing cancer diagnosis and treatment in those areas.

I'd suggest to our clinicians that even though this episode is about doing less and the trend that's going on in that area, there are certain areas where we want to do more. And that means paying attention to what matters to those aspects, the person's macro environment, if you will, their behavioral components of it. And the tools that we have both on the website at Healing Works Foundation, we try to...

point to in the book, such as the personal health inventory derived from the Veterans Administration and the Hope Note, really focus on what I would call personalized care, identifying what matters to the individual and trying to adapt the treatment plan and incorporate those things into their treatment component, acknowledging that it's not just.

Wayne Jonas (13:30.44)

cancer, but it's a person with cancer and that environment improves the quality and even the quantity of the patient's life in those areas. Is that something that you found useful in oncology and how do you apply that in cancer care?

Alyssa McManamon (13:48.017)

Yeah, I think, you know, really, again, knowing what matters to the person and having that conversation early on can help guide in terms of, you know, what treatments they would be more apt to benefit from in terms of, you know, that they would be able to either be on board for, tolerate well, that sort of thing. It's important to kind of start from knowing about them as an individual and also their goals. And so that does...

that does lend itself to shared decision making, which we'll probably talk about in another episode for sure.

Wayne Jonas (14:23.344)

Yeah, we have a whole episode on shared decision making. Probably could have called this session doing less and doing more. Because what we're really talking about is doing what's right for the person and integrating both the oncology team's perspective and the person's perspective into the treatment plan. There are a number of terms that float around in oncology and maybe we could talk a little bit about those. One is...

precision oncology and precision healthcare. Could you talk a little bit about what that is and how that is either different or overlaps with what's called personalized healthcare?

Alyssa McManamon (15:04.581)

Yeah, yeah, for sure. I mean, precision is kind of... Precision medicine, of course, is the new kid on the block, so to speak, you know, in the last number of years, five to ten years, where we're really thinking that way and using that term more often. It's really looking at, you know, how do we look at the tumor characteristics in terms of genetics, genomics. So the genetics of the person, say their germline, the genomics of the tumor, say mutations.

And then actually, we can use the term precision also regarding their environmental and lifestyle factors. I mean, we can use that term in all kinds of ways, but it really is being born out in really specific targeted potential tumor directed therapies. And I think it's here to stay and it is an example of doing less because we're in some ways not going to do things if the target's not there. And so we're trying not to blanket treat

every tumor the same. So from that standpoint, it's looking in some ways at doing more in terms of testing in order to do what is efficacious or useful.

Wayne Jonas (16:15.996)

Yeah, I think that's a great way to describe and to sort of distinguish those. I think the risk of course in precision oncology with the explosion of our detailed knowledge of the biology of cancer is that every little marker now becomes a target in a new therapy, right? And so people try that out, but so far that area has shown that, you know, just like any other intervention, it doesn't work 100% of the time.

And in some cases, it causes side effects. And so we, again, have to go back to good evidence, to good science, to determine when are these precision-focused treatments useful, when are they not useful, and how can they best be incorporated into cancer care, in ways that truly benefit the patient, both in terms of their quality and quantity of life. I think...

bringing in what the patient is looking for in terms of their overall goals needs to be part of merging that. And not simply chasing the latest thing that may not have totally good evidence in those areas. We see this also in alternative therapies, supplements and other types of things that many patients do and use. Most of those don't have a lot of good evidence that they're going to create benefit

in those areas and most of them are not researched in a rigorous way, you know, like we try to do in conventional drug treatment areas. And most of them are available to just simply buy online and over the counter, not regulated. And so I find myself having discussions with patients often when they come in with a bag full of supplements or in some cases off-label drugs about doing less of that if there's notevidence. Is that something you also have experienced?

Alyssa McManamon (18:18.717)

People will bring lists. If they have a long list, I'll certainly ask them to bring the bottles to really see what's actually in the names of the things, if they're not just single-agent herbal supplements. So I think, yes, it can be important to do less in that way because of all the issues with making sure things work together well and that there's not a need to stop something that might be unsafe, that's for sure.

I think the idea here is really trying to make everything fit to the person in front of us. In that sense, there's a personalization that goes on based out of really getting to know what they're doing outside the clinic, their ability to maybe comply with treatment or to be on the treatment that we're proposing. Those are all important things to figure out and that really happens in conversation.

Wayne Jonas (19:13.392)

Yeah. And, you know, there are places that clinicians and oncologists can go to get good information about that. The National Cancer Institute has websites that go over the evidence of that. Memorial Sloan Kettering has a website that talks about drug supplement nerve interactions in those areas that you can go to that's evidence-based in those areas. Could we talk a little bit about the area of palliative care?

Because oftentimes palliative care, at least when it is contextualized in the context of hospice, looks like you're doing less for the person. But palliative care is a much broader concept than simply hospice care, isn't it? I mean, it really is about helping the person feel better and get the best kind of quality of life going. Can you talk a little bit about the importance of palliative care

across the lifestyle? I believe this upcoming ASCO meeting, American Society of Clinical Oncology meeting is going to have a big emphasis on palliative care and its appropriate use across the cancer and treatment journey.

Alyssa McManamon (20:27.849)

Yeah, I think you've pointed out, I mean, palliative care can occur at any time. And so, you know, it can be appropriate for alleviation of suffering and symptoms at any time in the cancer treatment sort of paradigm. And really that distinction that it can be, it's always that difficult conversation, you know, with patients to try and just make sure that the terminology is understood. And so I think that palliative care is appropriate at any time.

Just like there's a shortage of oncologists, there's a shortage of palliative care physicians, but before that was a practice specialty with a board certification, oncologists considered themselves palliative care physicians, right? They were doing palliative care along with oncology and we're lucky now to have board certified palliative medicine doctors. And it's just a question of training more and having more available to patients and having that be, you know,

best case scenario on site and even your oncology clinic having a palliative medicine specialist present. And so I think that you know the idea of you know doing less, doing more it just it's kind of it's all it's all connected so oftentimes you know we are doing more to alleviate suffering if somebody say is in hospice enrollment because then we're not trying to balance other aspects of the tumor treatmeant.

That is a definition of six months or less life expectancy for somebody to be covered for hospice benefits. And so that's a different part of the spectrum than palliative only.

Wayne Jonas (22:06.804)

In my experience, I find that there's a role for palliative care physicians that has been tremendous, but it's not really described very much in the literature. And that is their ability to integrate across specialties. I've had patients that have been in the hospital, being seen by the surgeons because they might have a surgical intervention

needed to be seen by the medical side and the oncologist side, coordinating both inpatient and outpatient in those areas. And having somebody in palliative care come in and look at that, be part of that, sit with a patient, identify what it is that they personally need, often they can serve as an integration factor across all those different silos of care in a more effective and efficient way

and really move and provide the kind of framing to help make decisions that truly are person-centered and whole person care in those areas. And so it's not simply about symptom management, in my opinion, that role, which doesn't require, necessarily require a board-certified palliative care physician. I mean, anybody serving that role as an integrator that has the whole person in mind and pulls those different things can help de-silo you know, that type of care that we run into in medicine so much and overall provide better care.

Alyssa McManamon (23:37.889)

Agreed.

Wayne Jonas (23:40.18)

The one thing that we did want to talk about was the importance of words and the relationship to what's sometimes called the placebo or the nocebo effect, the negative aspects of placebo. And certainly when it comes to cancer care, the words have huge power. The very words, you know, you have cancer. Those three little words, right, can suddenly...

you know, strike fear into the heart of patients and their families, you know, even the care team and launch is an entire effort to try to address that in those areas. But the way we communicate that it can either exacerbate the harm that fear-driven approach can produce or can actually alleviate it. 

Can you talk a little bit about how we avoid the nocebo effect in our communication with patients?

Alyssa McManamon (24:42.901)

Yeah, if we're talking about communication around, say, a treatment or whatnot with potential side effects, I think the Nocebo Effect then is really the concept of applying statistics to, say, the individual in front of you and presenting all potential side effects as if they will either definitely occur, which would be that's not what we want to do because we don't know that upfront, but there is an impact to that. So if the languaging that's used to describe potential side effects is that...

you know, you will experience this, and it's really applied to the entire list of which there are numerous things that are discussed that is probably not gonna serve the patient as well. What we typically try and do is to, you know, think about how do we tailor this based on what we've seen in the past, maybe what this patient already has as some baseline medical conditions and go from there. But there is evidence that the Nocebo effect creates symptoms in patients, as you said, meaning nearly like through the power of suggestion. 

So saying something will cause, for example, GI issues. If that is true and has been true for all my patients, I'm going to share what I know to be true up until this point. I'm going to say, you know, many patients that I've treated with this agent have had diarrhea. It doesn't mean you're going to have diarrhea, but I'm just letting you know that is something that I've seen. And I think, you know, that's different than saying you will have diarrhea and so the languaging there is important and that's the best example think I can give.

Wayne Jonas (26:15.348)

I think that's an excellent example. And for listeners, the crux to this really is about how you communicate data, which is generic data that's collected in controlled studies, which is average data over a wide spectrum of patients. And whether you actually say that is going to be the person sitting in front of you, which we can't know actually

because we don't know where on that spectrum this person is going to fall. So you said the key word, Alyssa, that is the important and careful use of the word you. And, you know, not saying this is going to be you, but this is on average what happens, and you could fall anywhere in this spectrum, including on the side where it doesn't happen.

The same thing is important in prognostic information. People get diagnosed with cancer and very often they immediately go online and they look up their statistics, the prognostic. You know, what are my chances of living five years, for example, which you can find anywhere. And when they come in to talk to you about that, you're in a position of authority. They're gonna be listening to you as the expert in those areas. And if you then take that aggregate data, which is very generic over...

many, many types of patients and say, this is gonna be you, that can be damaging. So communicating that this isn't necessarily you, or you could fall into the much higher prognostic or better prognostic factor in those areas. Our body language makes a big difference. Research from mind-body practices, psychotherapy, hypnosis, et cetera, have demonstrated that when there is a...

sort of a power relationship where an authority is there and someone who feels now helpless with a diagnosis is in a lower relationship, there's almost a hypnotic context in which that can occur. So being very careful about those words can be really important. And we'll talk about this in future shared decision making concept as you've mentioned, but I think paying attention to those things

Wayne Jonas (28:32.064)

can make a big difference in terms of making sure we do less harm in a situation that's already scary and where we sometimes have to do harm to patients in order to help them recover and get better. So you wanna say any final comments here before we wrap this episode up?

Alyssa McManamon (28:53.449)

I mean, just I think it kind of brings up the end of one idea, you know, that the person in front of you when you're talking about prognosis, they truly are, you know, kind of in their own clinical trial of one and they're, you know, they're going to have whatever outcome that they do have and that we use the statistics to try and help guide them in terms of possibility and probability, but it is still kind of their own experience and their own

you know, path that unfolds and to support them through that. And I think that's what gives people hope as well to realize that they are an individual. And we want to support, you know, support their individuality as they go through.

Wayne Jonas (29:36.152)

That's great. Well, thank you. And in our subsequent episode on shared decision making, I'd like to highlight a recent article in the New England Journal of Medicine that just came out that gave an example of some of the challenges in these discussions and how they can be addressed. And we'll talk further about making sure that what works and for who in the right context and when is something that all people can use in oncology care and all patients can experience in routine care.

Alyssa McManamon (30:09.809)

Yeah, I mean, Wayne, do you have a thought right now just about how physicians can better support their patients' decision making, like outside of, you know, what was discussed?

Wayne Jonas (30:20.532)

Well, I think the importance of spending time and learning about what the goals are of the patient can be overemphasized because we don't have enough time to do that. We don't spend enough time doing that. And yet, creating a partnership with the patient, it becomes key. A trusting relationship where that communication,

that hypnotic environment that I mentioned earlier, can be used in a positive way. So I use something called the 4Ps approach to patients. Number one, protect them from harm and make sure they're not getting into something that actually is going to harm them. That's the first tenet of medicine, right? Do no harm. Permit things that aren't going to produce harm, but empower them, but they engage them in their activity and use the power of even nonspecific

effects to bring them into their own engagement and their own self-care. Promote those things that the evidence says are beneficial, even if it involves doing less or increasing the amount of palliative care earlier than we might do. But in all cases, partner with a patient. And that means sitting down, finding out what's important to them and what their goals are in going through this journey and aligning our plan along with that. So those are the tools that we're trying to kind of bring more and more into cancer care. And hopefully as we go through these episodes and with the book and the other supporting materials, people can do that in a more routine fashion.

Alyssa McManamon (32:06.005)

Thanks, that's great. 

Wayne Jonas (32:41.32)

Well, thank you everybody for listening to How Healing Works.