September 13, 2024 • 11 mins
Welcome to episode three of three. In this episode, Dr. Alex Spira and Dr. Josh Zabari, both experts in thoracic oncology, delve into the common side effects experienced by patients undergoing treatment for locally Advanced or Metastatic EGFR+ Non-Small Cell Lung Cancer (NSCLC). They discuss the importance of early identification and management of these side effects to optimize patient care and prevent treatment discontinuation. Listen in to review strategies for addressing dermatologic and gastrointestinal toxicities, the role of multidisciplinary teams, and the significance of continuous communication with patients and caregivers.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:04):
Welcome to the Management and Proactive Care of Adverse Events Associated with
Locally Advanced or Metastatic EGFR-Positive NSCLC Treatment episode of the
Practice to Practice podcast series.
This educational podcast is brought to you by Johnson & Johnson and is not certified
for continuing medical education.
The consultants in this podcast were paid by Johnson & Johnson and must present
(00:29):
information in compliance with FDA requirements applicable to Johnson & Johnson.
I'm Alex Spira. I'm a medical oncologist mainly focusing on thoracic malignancies.
I'm a Virginia cancer specialist in U.S. oncology. I see about a couple hundred
patients a year with non-small cell lung cancer.
I'm Josh Zabari, thoracic medical oncologist at NYU Langone Health Perlmutter
(00:50):
Cancer Center in New York. I also focus on thoracic oncology,
seeing a couple of hundred patients a year with lung cancer.
Alex, what side effects do you see most often in patients being treated for
locally advanced or metastatic EGFR mutant non-small cell lung cancer?
For the patients currently undergoing first-line therapy, a lot of the EGFR-related
toxicities that we see, and I'm sure it's probably pretty similar for you, is skin rash,
(01:13):
nail bed changes, skin cuts, hair texture changes, and occasionally some GI
side effects like diarrhea. Yeah, I would agree.
I think in the frontline setting for metastatic EGFR mutant lung cancer,
most of the time patients are reporting some fatigue, but we do have patients
who have no symptoms or side effects at all.
Over time, more chronically, we do see a lot of skin changes.
(01:33):
You can see somewhat of an acne form rash that could develop on the chin or
the lips, the nasolabial folds.
You can see some paronychia or some skin breaks in the fingertips,
especially in the cold weather. And then you can also see very mild diarrhea in some patients.
Again, Again, these are all pretty minimal or mild side effects,
but over time, the chronicity of them can definitely affect patients' quality of life.
(01:54):
I'm always amazed when you see a new patient with a heavy or large burden of disease.
They oftentimes are not complaining about the side effects. It's more so down the road.
Why is it important to proactively anticipate side effects in order to optimize
the treatment experience for patients receiving treatment for locally advanced
or metastatic EGFR-mutated non-small cell lung cancer?
Identifying side effects and managing them appropriately early on is critical,
(02:17):
particularly in patients treated with targeted therapy.
If we can identify these toxicities early, mitigate those to prevent dose reduction
or, more concerning, dose discontinuation, patients can achieve longer,
more durable responses to these therapies. How are you addressing these with your patients?
I think there's two things of concern. One is you feel bad. A patient's having
a side effect, and if they're not managing the side effect adequately,
(02:39):
they're not feeling good because of it.
And then the thing you alluded to very eloquently, of course,
is these are targeted therapy.
If you don't stop the target that's signaling the cancer cell,
the cancer is going to grow. A one-day or one-week delay in a drug is not going
to have a big adverse event.
But if somebody has a bad cellulitis and you're forced to hold the drug,
you're giving that patient's tumor time to grow.
Once new side effects do arise, what is your approach to management and what
(03:02):
steps do you take to avoid treatment discontinuation?
So I think a couple of things. One, as we talk about management of this,
is how significant is it?
If somebody has a little bit of a rash or a little bit of a skin break on their
finger, it can be mild and patients might be fine with it.
And of course, every patient has different tolerability.
For dermatologic toxicities, I typically think about creams.
Everybody's got kind of their different cream. If it's on the face,
(03:24):
it's on the scalp. Sometimes you use steroid creams, sometimes you use topical antibiotics.
For paronychia, I'm trying to be a little bit more proactive about moisturizers.
Wintertime is always tough. People's skin gets dried out.
I am telling all patients to use thick, white, lubricating-type cream.
I try to stay away from oil-based creams and fragrant creams.
I tell patients, go to the drugstore, get the cheapest thing you can find that
(03:46):
is going to lubricate your hands.
I think that's been very helpful in sort of the prophylactic measures.
Some of the reactive measures that we take is that when those are not enough,
the lubricating creams and patients do have more skin breaks or do get infections,
having them see dermatology can be very helpful.
But also asking patients if they're predisposed to things or if someone has
dry skin to start with, maybe I'll be a more little preventative.
(04:09):
There are patients that I've sent to dermatology prophylactically because they
have underlying things like eczema, psoriasis, or high-risk dry skin issues.
We also can do topical steroids or even sometimes cauterization to some of the
nail beds if the peronechia is quite severe.
And liquid Band-Aids, I found, have been very helpful for these patients with the skin breaks.
You do see patients come in with four or five Band-Aids on their hands,
(04:32):
sometimes on their toes as well.
So really, if we can prophylactically treat this, it's going to be critical.
GI symptoms, I sometimes try and manage with antidiarrheals.
I'm usually not doing that proactively, but if people are going too often,
shall we speak, I try and make sure that they're staying on top of their anti-diarrheals,
sometimes changing their diet a little bit, a little bit less milk products,
finding foods that make sense.
(04:54):
I don't necessarily see GI symptoms as commonly, but diarrhea,
I don't prophylactically use any medications up front.
If patients are having severe diarrhea, we do use the anti-diarrheals.
I'm more of a reactive strategy.
But again, depending on the toxicity, one toxicity where I am very proactive
is venous thromboembolism.
So in a patient with a history of VTE, for example, or family history,
(05:18):
I would preventive start anticoagulation therapy.
No, absolutely. And I think this is where it's hard to know your patient.
Every institution is different as well.
I think two schools of thoughts. There are patients that want to do everything prophylactically.
But of course, with doing that comes more creams, more ointments,
more pills, more things that are impacting their daily lives.
I think upfront, we do spend a lot of time going over side effects and toxicity management.
(05:43):
But you're right. It's more chronic. The chronicity of these.
At later visits, I think it's important to continually ask, are you having skin rash?
Are you having any skin toxicities? Are you having any GI toxicities such as
diarrhea, upset stomach, bloating?
I think these are critical to continue to ask patients over time.
And something I personally found very helpful is to set guardrails around the
(06:03):
toxicity or the side effects.
Telling patients if you have fever, anything greater than 100.4,
give us a call. And obviously telling the family members about that as well.
In the EGFR mediated space, I think, you know, just saying if you have rash,
call me, but really putting guardrails around it.
Dry skin versus the acneiform rash versus if there's any infection,
any signs of a super infection or pus development in the perinechia or on the
(06:28):
face, that's critical for us to know so that we can intervene early.
With GI toxicities, a loose bowel movement here or there and letting us know
if it's getting more significant into that grade two range.
So maybe three, four bowel movements
a day, and that's significant for patients, we need to know that.
So I like to quantify the toxicities with patients and I like to give them and
(06:48):
their family these guardrails.
It's critical to not only give this information upfront.
Discuss this in an ongoing fashion throughout their course and throughout their care.
Alex, what strategies do you use to ensure early recognition of these side effects?
I think a couple of things. One is we try and reach out to the patients with
a lot of touch points. We want to make sure that the patients call in if they're having any side effect.
(07:09):
You want to see the patients at enough of a frequency, but of course not too
much, so they can ask a lot of questions and kind of go over the side effects.
And I also think it's super important that we have patients,
caregivers, and other care team members.
We have nurses, We have APPs, we have pharmacists, we have lots of people checking
in and asking these questions.
Hopefully, a lot of these questions can be answered if it's a mild side effect.
(07:31):
But obviously, as things get more significant or severe, they can talk about
these side effects and we can come up with a remedy to make the patients feel better.
Like you mentioned, it's a team. It takes a family to take care of our patients these days.
Our APPs, our nurse practitioners have become critical in fielding a lot of
these toxicity questions and a lot of the checking in. And I think you need
to do this preventatively, prophylactically.
(07:52):
You can't wait until a patient has dramatic toxicity.
At that point, it may be already too late. I think getting family involved is critical.
We all have older patients in our practices who, you know, might need a little
bit of help or tender, loving care.
Getting their family member involved or caregiver or aid pays dividends in hearing
and understanding their toxicities.
(08:13):
Unfortunately, there's a lot of people, especially in the older patient population.
Widowed, divorced, no children, kids live far away, and they're doing this on their own.
And I think it behooves us and it's on us to make sure that we have all the
support, even if it starts as a social worker, somebody to know that there are
these other resources out there.
Because again, you know, when we're trying to treat cancer, we have to stay
on top of their cancer treatment because that's the only thing that's going to help them.
(08:34):
What are some of the best practices you have for working with patient,
caregiver, and the multidisciplinary care team when you're managing some of these side effects?
First off, understanding that we're not the only touch point in the system.
There's nursing, as we mentioned, there's pharmacists, and there are other subspecialists.
For example, if someone has a rash or, you know, paronychia that becomes more
severe, patients are often referred to dermatology.
(08:55):
So there are many other subspecialists that are involved in the care.
So I would say on a weekly basis, we are in contact with other members of a
the patient's care team.
And I think that's the mark of a good model where you can actually have multiple
people all sort of on the same page, all taking care of the patient,
making sure and managing symptoms and side effects correctly.
Don't forget the primary care physician remains a critical touch point throughout
(09:20):
a patient's cancer journey.
A lot of times patients have that deep relationship that you mentioned with
their PCP, their primary care physician.
And that for me is also an asset. I will oftentimes reach out to the primary
care doc to introduce myself up front but also to touch base throughout their course.
I think we have lots of ways of communicating. We have secure chat through our EMR.
We can just walk around the corner depending on where your clinic is and your
(09:42):
nurse is there or your APPs might sit.
There's lots of different ways to obviously communicate with everybody.
Your academic practice is different than mine, community-based.
I'm sure it's all the same people that are involved at some level.
At least for me, we don't have routine meetings, but literally we try and meet
every day when we're talking about patients, especially when the patients come into clinic.
They'll often see me, see the APP and see the nurse as well.
(10:05):
And I think patients like doing that as well. They feel like they're not just
coming in for doctors, they're coming in to visit their care team.
So Alex, exciting discussion on EGFR mutant lung cancer, really critical to
understand toxicities early and to mitigate them to prevent dose reduction and
dose discontinuation in order to see efficacy.
It's really been great having this discussion with you today.
(10:25):
It's great getting back together with you, Josh.
Again, just to reiterate, it's super important to know how to manage these toxicities.
Use your entire team, lots of people involved, lots of touch points,
and making sure you're staying on top of some of these side effects so patients
can stay on their anti-cancer therapy.
This episode was approved under CP429521V1. For more practice-to-practice podcast
(10:49):
videos For more videos and other information on locally advanced or metastatic EGFR-positive NSCLC,
please visit EGFRroutes.com.
Welcome to the Management and Proactive Care of Adverse Events Associated with
Locally Advanced or Metastatic EGFR-Positive NSCLC Treatment episode of the
Practice to Practice podcast series.
This educational podcast is brought to you by Johnson & Johnson and is not certified
for continuing medical education.
The consultants in this podcast were paid by Johnson & Johnson and must present
(00:29):
information in compliance with FDA requirements applicable to Johnson & Johnson.
I'm Alex Spira. I'm a medical oncologist mainly focusing on thoracic malignancies.
I'm a Virginia cancer specialist in U.S. oncology. I see about a couple hundred
patients a year with non-small cell lung cancer.
I'm Josh Zabari, thoracic medical oncologist at NYU Langone Health Perlmutter
(00:50):
Cancer Center in New York. I also focus on thoracic oncology,
seeing a couple of hundred patients a year with lung cancer.
Alex, what side effects do you see most often in patients being treated for
locally advanced or metastatic EGFR mutant non-small cell lung cancer?
For the patients currently undergoing first-line therapy, a lot of the EGFR-related
toxicities that we see, and I'm sure it's probably pretty similar for you, is skin rash,
(01:13):
nail bed changes, skin cuts, hair texture changes, and occasionally some GI
side effects like diarrhea. Yeah, I would agree.
I think in the frontline setting for metastatic EGFR mutant lung cancer,
most of the time patients are reporting some fatigue, but we do have patients
who have no symptoms or side effects at all.
Over time, more chronically, we do see a lot of skin changes.
(01:33):
You can see somewhat of an acne form rash that could develop on the chin or
the lips, the nasolabial folds.
You can see some paronychia or some skin breaks in the fingertips,
especially in the cold weather. And then you can also see very mild diarrhea in some patients.
Again, Again, these are all pretty minimal or mild side effects,
but over time, the chronicity of them can definitely affect patients' quality of life.
(01:54):
I'm always amazed when you see a new patient with a heavy or large burden of disease.
They oftentimes are not complaining about the side effects. It's more so down the road.
Why is it important to proactively anticipate side effects in order to optimize
the treatment experience for patients receiving treatment for locally advanced
or metastatic EGFR-mutated non-small cell lung cancer?
Identifying side effects and managing them appropriately early on is critical,
(02:17):
particularly in patients treated with targeted therapy.
If we can identify these toxicities early, mitigate those to prevent dose reduction
or, more concerning, dose discontinuation, patients can achieve longer,
more durable responses to these therapies. How are you addressing these with your patients?
I think there's two things of concern. One is you feel bad. A patient's having
a side effect, and if they're not managing the side effect adequately,
(02:39):
they're not feeling good because of it.
And then the thing you alluded to very eloquently, of course,
is these are targeted therapy.
If you don't stop the target that's signaling the cancer cell,
the cancer is going to grow. A one-day or one-week delay in a drug is not going
to have a big adverse event.
But if somebody has a bad cellulitis and you're forced to hold the drug,
you're giving that patient's tumor time to grow.
Once new side effects do arise, what is your approach to management and what
(03:02):
steps do you take to avoid treatment discontinuation?
So I think a couple of things. One, as we talk about management of this,
is how significant is it?
If somebody has a little bit of a rash or a little bit of a skin break on their
finger, it can be mild and patients might be fine with it.
And of course, every patient has different tolerability.
For dermatologic toxicities, I typically think about creams.
Everybody's got kind of their different cream. If it's on the face,
(03:24):
it's on the scalp. Sometimes you use steroid creams, sometimes you use topical antibiotics.
For paronychia, I'm trying to be a little bit more proactive about moisturizers.
Wintertime is always tough. People's skin gets dried out.
I am telling all patients to use thick, white, lubricating-type cream.
I try to stay away from oil-based creams and fragrant creams.
I tell patients, go to the drugstore, get the cheapest thing you can find that
(03:46):
is going to lubricate your hands.
I think that's been very helpful in sort of the prophylactic measures.
Some of the reactive measures that we take is that when those are not enough,
the lubricating creams and patients do have more skin breaks or do get infections,
having them see dermatology can be very helpful.
But also asking patients if they're predisposed to things or if someone has
dry skin to start with, maybe I'll be a more little preventative.
(04:09):
There are patients that I've sent to dermatology prophylactically because they
have underlying things like eczema, psoriasis, or high-risk dry skin issues.
We also can do topical steroids or even sometimes cauterization to some of the
nail beds if the peronechia is quite severe.
And liquid Band-Aids, I found, have been very helpful for these patients with the skin breaks.
You do see patients come in with four or five Band-Aids on their hands,
(04:32):
sometimes on their toes as well.
So really, if we can prophylactically treat this, it's going to be critical.
GI symptoms, I sometimes try and manage with antidiarrheals.
I'm usually not doing that proactively, but if people are going too often,
shall we speak, I try and make sure that they're staying on top of their anti-diarrheals,
sometimes changing their diet a little bit, a little bit less milk products,
finding foods that make sense.
(04:54):
I don't necessarily see GI symptoms as commonly, but diarrhea,
I don't prophylactically use any medications up front.
If patients are having severe diarrhea, we do use the anti-diarrheals.
I'm more of a reactive strategy.
But again, depending on the toxicity, one toxicity where I am very proactive
is venous thromboembolism.
So in a patient with a history of VTE, for example, or family history,
(05:18):
I would preventive start anticoagulation therapy.
No, absolutely. And I think this is where it's hard to know your patient.
Every institution is different as well.
I think two schools of thoughts. There are patients that want to do everything prophylactically.
But of course, with doing that comes more creams, more ointments,
more pills, more things that are impacting their daily lives.
I think upfront, we do spend a lot of time going over side effects and toxicity management.
(05:43):
But you're right. It's more chronic. The chronicity of these.
At later visits, I think it's important to continually ask, are you having skin rash?
Are you having any skin toxicities? Are you having any GI toxicities such as
diarrhea, upset stomach, bloating?
I think these are critical to continue to ask patients over time.
And something I personally found very helpful is to set guardrails around the
(06:03):
toxicity or the side effects.
Telling patients if you have fever, anything greater than 100.4,
give us a call. And obviously telling the family members about that as well.
In the EGFR mediated space, I think, you know, just saying if you have rash,
call me, but really putting guardrails around it.
Dry skin versus the acneiform rash versus if there's any infection,
any signs of a super infection or pus development in the perinechia or on the
(06:28):
face, that's critical for us to know so that we can intervene early.
With GI toxicities, a loose bowel movement here or there and letting us know
if it's getting more significant into that grade two range.
So maybe three, four bowel movements
a day, and that's significant for patients, we need to know that.
So I like to quantify the toxicities with patients and I like to give them and
(06:48):
their family these guardrails.
It's critical to not only give this information upfront.
Discuss this in an ongoing fashion throughout their course and throughout their care.
Alex, what strategies do you use to ensure early recognition of these side effects?
I think a couple of things. One is we try and reach out to the patients with
a lot of touch points. We want to make sure that the patients call in if they're having any side effect.
(07:09):
You want to see the patients at enough of a frequency, but of course not too
much, so they can ask a lot of questions and kind of go over the side effects.
And I also think it's super important that we have patients,
caregivers, and other care team members.
We have nurses, We have APPs, we have pharmacists, we have lots of people checking
in and asking these questions.
Hopefully, a lot of these questions can be answered if it's a mild side effect.
(07:31):
But obviously, as things get more significant or severe, they can talk about
these side effects and we can come up with a remedy to make the patients feel better.
Like you mentioned, it's a team. It takes a family to take care of our patients these days.
Our APPs, our nurse practitioners have become critical in fielding a lot of
these toxicity questions and a lot of the checking in. And I think you need
to do this preventatively, prophylactically.
(07:52):
You can't wait until a patient has dramatic toxicity.
At that point, it may be already too late. I think getting family involved is critical.
We all have older patients in our practices who, you know, might need a little
bit of help or tender, loving care.
Getting their family member involved or caregiver or aid pays dividends in hearing
and understanding their toxicities.
(08:13):
Unfortunately, there's a lot of people, especially in the older patient population.
Widowed, divorced, no children, kids live far away, and they're doing this on their own.
And I think it behooves us and it's on us to make sure that we have all the
support, even if it starts as a social worker, somebody to know that there are
these other resources out there.
Because again, you know, when we're trying to treat cancer, we have to stay
on top of their cancer treatment because that's the only thing that's going to help them.
(08:34):
What are some of the best practices you have for working with patient,
caregiver, and the multidisciplinary care team when you're managing some of these side effects?
First off, understanding that we're not the only touch point in the system.
There's nursing, as we mentioned, there's pharmacists, and there are other subspecialists.
For example, if someone has a rash or, you know, paronychia that becomes more
severe, patients are often referred to dermatology.
(08:55):
So there are many other subspecialists that are involved in the care.
So I would say on a weekly basis, we are in contact with other members of a
the patient's care team.
And I think that's the mark of a good model where you can actually have multiple
people all sort of on the same page, all taking care of the patient,
making sure and managing symptoms and side effects correctly.
Don't forget the primary care physician remains a critical touch point throughout
(09:20):
a patient's cancer journey.
A lot of times patients have that deep relationship that you mentioned with
their PCP, their primary care physician.
And that for me is also an asset. I will oftentimes reach out to the primary
care doc to introduce myself up front but also to touch base throughout their course.
I think we have lots of ways of communicating. We have secure chat through our EMR.
We can just walk around the corner depending on where your clinic is and your
(09:42):
nurse is there or your APPs might sit.
There's lots of different ways to obviously communicate with everybody.
Your academic practice is different than mine, community-based.
I'm sure it's all the same people that are involved at some level.
At least for me, we don't have routine meetings, but literally we try and meet
every day when we're talking about patients, especially when the patients come into clinic.
They'll often see me, see the APP and see the nurse as well.
(10:05):
And I think patients like doing that as well. They feel like they're not just
coming in for doctors, they're coming in to visit their care team.
So Alex, exciting discussion on EGFR mutant lung cancer, really critical to
understand toxicities early and to mitigate them to prevent dose reduction and
dose discontinuation in order to see efficacy.
It's really been great having this discussion with you today.
(10:25):
It's great getting back together with you, Josh.
Again, just to reiterate, it's super important to know how to manage these toxicities.
Use your entire team, lots of people involved, lots of touch points,
and making sure you're staying on top of some of these side effects so patients
can stay on their anti-cancer therapy.
This episode was approved under CP429521V1. For more practice-to-practice podcast
(10:49):
videos For more videos and other information on locally advanced or metastatic EGFR-positive NSCLC,
please visit EGFRroutes.com.
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