January 2011

Palliative Care Is Not Giving Up — IR’s Role in Palliative Treatment in Oncology
By Shaun Samuels, MD
Radiology Today
Vol. 12 No. 1 P. 34

Whether performing chemoembolization for liver metastasis or radio-frequency ablation for painful bone lesions, interventional radiologists often provide oncologic treatment that is palliative rather than curative. Despite this, many of these “interventional oncologists” do not fully understand the meaning and importance of palliative care and how it can fit into a patient’s overall treatment plan. Interventional oncologist is a shorthand term for interventional radiologists focused on the treatment of cancer patients; it does not imply that interventional radiologists have training commensurate with fully trained oncologists.

To move the palliative care conversation forward, the Symposium on Clinical Interventional Oncology, which was held in conjunction with International Symposium on Endovascular Therapy (ISET), hosted the session “Making Lives Better: A Look at Palliative Care” at the meeting in Miami Beach this month. Physician talks focused on how interventional radiology can be of greater service to hospice and palliative care providers by offering better, more durable venous access in oncology patients and by judicious use of catheters for optimizing chronic drainage strategies in the chest. But the symposium also included discussions by leading nurses who handle the lion’s share of palliative care regarding the definition and scope of palliative care: what hospice means and when it makes sense for the patients we treat.

My sense is that most interventionalists don’t fully appreciate the fact that most of what we do is palliative rather than curative. We understand that we are treating metastases, for instance, yet we believe we are doing something active, something that will extend the patient’s life. We may not give proper thought to the impact of the postprocedural symptoms, including their severity or duration. In some instances, it is arguable that the “cure” is worse than the disease, that the extension of a life by a few weeks with a procedure that itself may cause months of debility is not, by a patient’s measure, worthwhile.

This is understandable in Western medicine’s never-say-die approach to healthcare. There is always another treatment to try, another surgery that may be beneficial. In the minds of most people—including, and perhaps especially, doctors—palliation equals failure. Palliative care is what you provide when you’ve given up. That’s far from true, of course, but it is understandable how such a view may become commonplace.

Extending Lives and Quality
Research has repeatedly shown that people with serious illness who receive hospice and palliative care not only achieve better quality of life but actually live longer. Consider a study that looked at the use of early palliative care in patients with metastatic non–small-cell lung cancer recently published in The New England Journal of Medicine. The authors found that patients who received early palliative care had less aggressive care at the end of life yet lived about two months longer compared with those who received the standard of care.

Palliative care provides far more than pain and symptom relief for people with serious illness, even though that relief is beneficial in and of itself. Palliative care providers also guide patients and families in making difficult medical decisions by explaining the benefits and the burdens of potential treatments. They work with patients and families, considering their desires, goals, and concerns when making a plan for how to get the most out of a patient’s remaining time. They also provide the emotional and spiritual support that ailing patients and their families desperately need and want.

The goal of the Symposium on Clinical Interventional Oncology was, at the very least, to foster a better understanding of what palliative care entails by demystifying it. I hope attendees gained a deeper appreciation of palliative care and will be more willing to make use of it by suggesting it to patients and their families. I would like attendees to know how interventional oncologists fit into the palliative care picture as well as all the tools and services that we may offer.

Ideally, interventional oncologists will work more closely with the palliative care team, which frequently can include a physician who specializes in hospice and palliative medicine (such as interventional oncology, a newer and often unappreciated specialty), in addition to nurses, patients and their families, social workers, pharmacists, dietitians, and volunteers. Although interventional oncologists aren’t usually the decision makers, I’m hopeful we’ll become more involved so that we are comfortable suggesting to the medical oncologist when we believe palliative measures may be beneficial. The goal is to enable healthcare providers—all of us—to better serve our patients.

— Shaun Samuels, MD, is an interventional radiologist at Baptist Cardiac & Vascular Institute in Miami and affiliate assistant professor at the University of South Florida at Tampa.


Treating Hamstring Injury With Patient’s Own Blood
Researchers in London say they have found an effective two-part treatment for microtears in the hamstring: injections of a patient's own blood and a steroid along with a "dry-needling" technique in which repeated needle punctures cause controlled internal bleeding in the injured area.

“By injecting the patient's own blood where it is needed at the site of a damaged tendon, we help the patient heal themselves,” said lead researcher Waseem A. Bashir, MD, a radiologist at Royal National Orthopaedic Hospital and Ealing Hospital in London who presented results from a study on the technique at RSNA 2010. “Blood contains many growth factors, and the injections have been shown to promote faster healing of certain injuries.”

Hamstring tendinopathy is a common sports injury that occurs in soccer, gymnastics, karate, and any other sport that requires quick acceleration. Unlike a torn or ruptured tendon that can be surgically repaired, the tiny microtears that characterize chronic tendinopathy are not easily diagnosed, are difficult to heal, and often sideline athletes for long periods, if not permanently.

“Patients with hamstring tendinopathy will experience pain walking or climbing stairs and even while sitting or riding in a car,” Bashir said. “The condition is literally a pain in the butt.”

In the study, 42 patients with suspected hamstring microtearing underwent ultrasound and MRI to confirm the tendinopathy. The patients were randomly assigned to one of three treatment groups. The first group received an injection of both a long-lasting anesthetic and a steroid on the surface of the tendon as well as the dry-needling procedure at the site of microtears. The second group received an injection of the anesthetic along with 2 to 3 mL of their own blood, called an autologous blood injection (ABI), and dry needling. The third group received a local anesthetic, a steroid, and ABI along with dry needling.

“The injections were all performed with ultrasound and color Doppler, which allows us to watch in real time where the needle is going,” Bashir said. “During the dry needling, we can see blood flow increase in the area.”

All patients in the study participated in a structured six-week physiotherapy program and were evaluated during a one-year period. Patients treated solely with an injection of a steroid and dry needling reported improved functionality for only three to 12 weeks after treatment. One year later, patients in this group reported being at pretreatment levels of pain and functionality. Patients who received their own blood plus dry needling reported significant improvements in functionality even one year after the treatment. Patients who received both their own blood and a steroid along with dry needling at the site of tendon damage experienced the most significant reduction in pain levels and the most sustained functional improvement one year following treatment.

"A few of our soccer-playing patients had been told their condition was untreatable, and they had basically given up all hope of playing again. They were amazed to be able to play again after our treatment and physical therapy,” Bashir said.

He added that ABI therapy has been an effective treatment for microtears in other tendons, including those at the elbow, the patellar tendon, and those in the rotator cuff within the shoulder.

— Source: RSNA