Palliative Care for Oncologists: the Value of Integrated Palliative Care Training During Fellowship With Richa Thakur, MD

Oncology Data Advisor: Welcome to the Oncology Data Advisor Fellows Forum. Today I have the pleasure of being joined by Dr. Richa Thakur, who is a Palliative Care Physician and a Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. Dr. Thakur, thank you so much for coming on today.

Richa Thakur, MD: Oh, thank you so much for having me. I'm really excited to be here.

Oncology Data Advisor: Would you like you to introduce yourself and share what your work focuses on?

Dr. Thakur: Of course. My name is Richa. I'm a first-year Heme/Onc Fellow at Northwell, and before I started my heme/onc fellowship, I also did a fellowship in palliative care. Because I've done both of these, it's part of what my research interest is. I am really interested in quality-of-life improvements in patients with hematologic malignancies. Usually, most palliative care research focuses on cancer patients with solid tumors because the trajectory of their disease is much easier to predict. But with hematologic malignancies, most of the time you're going for curative intent. It becomes much more difficult to incorporate palliative care, even though we know how great palliative care can be in this population.

Oncology Data Advisor: What is the current need for palliative care education for oncology clinicians, specifically for fellows?

Dr. Thakur: I would say there's a significant amount of need. Typically, with oncologists, about 80% work outside of a National Cancer Institute (NCI)–designated cancer center or an academic institution. Most of these are oncologists that work in the community and are really taking care of the bulk of patients with cancer in the country. These are patients who usually would not have access to a specialty-trained palliative care physician very easily, because of geographical barriers too. For an oncologist to be very good at managing primary palliative care needs, and at least some secondary palliative care needs, is really essential. I think having fellows do more palliative care rotations would only be beneficial to making them better oncologists.

Oncology Data Advisor: Definitely. How do you approach palliative care in your practice?

Dr. Thakur: I think it's definitely changed since I started my heme/onc fellowship. Obviously when I was a Palliative Care Fellow, I only had to focus on palliative care. As a Heme/Onc Fellow, the way I incorporate it really depends on patient to patient. Generally within the first two to three visits of seeing the patient, I try to do a full palliative care assessment on them. To me, that includes doing a good social history, basically addressing advanced care directives, and doing a symptoms assessment, which I don't do at just the beginning but at every single visit. Then obviously as their disease trajectory changes, I readdress goals of care and advanced care planning throughout their treatment course.

Oncology Data Advisor: Are there any barriers to accessing palliative care for patients?

Dr. Thakur: Unfortunately, there are quite a few. I think one of the biggest barriers we have is just access to good palliative care services for most of our cancer patients. Having oncologists that are trained in palliative care will not only help this but will also make it easier for the future generation of physicians to refer to palliative care more easily. Other barriers I've noticed are a lot of misperceptions about palliative care. Unfortunately, this isn't just with our patient population; it's with other medical staff members including nurses, other physicians, and even some oncologists.

Oncology Data Advisor: How do you go about approaching these barriers?

Dr. Thakur: I think one of the biggest things about the misperceptions is trying to frame everything when you present it to a patient as how it could help them. Oftentimes, patients think that palliative care means end of life. To be honest, palliative care is really applicable from the time of diagnosis for these patients. Palliative care physicians help with complex medical decision making, symptomatology and making sure that patients know that they are here to address them throughout the full course of their illness and treatment. It can only help.

One of the best tools I've found to help frame this for patients is a really good analogy. I did send that paper in, so hopefully you guys can read it. It's about describing palliative care as an umbrella. The way I approach this is I tell my patients, "When you have cancer, there are a lot of negative things that can happen even when we're treating you well. Some of these can be side effects from your chemotherapy and your treatment, and other things can be side effects of the cancer growing. If you think of this as rain, one of the best tools you have to help rain is an umbrella. The best time to actually bring in an umbrella is not when you're outside in the rain, but it's to have it before."

Calling palliative care earlier on is the best way to make sure that these patients have the tools they need and are able to access it early on, before their symptoms burden is so significant that they're not able to tolerate their treatment anymore.

Oncology Data Advisor: Absolutely, that's a great analogy. Are there any resources you'd recommend for anyone who's interested in learning more about palliative care, both for the clinicians themselves as well as resources they can share with patients?

Dr. Thakur: Absolutely. There are a couple of resources that I would recommend for clinicians who are just starting out. The American Academy of Hospice and Palliative Medicine (AAHPM) always has a ton of good modules and other resources and links that you can look at, as well as the Center to Advance Palliative Care (CAPC). Going through those modules at the beginning would really be a great way to get some basic introductory skills in not only symptom management, but also complex medical decision making and advanced care planning.

On top of that, especially for Oncology Fellows, we often have patients with significant symptoms. Using the GeriPal podcast as well as Fast Facts from the Palliative Care Network of Wisconsin are really helpful. Oftentimes, we're very familiar with using first- or second-line treatments for nausea, for example. But not all fellows know that you can use aromatherapy or olanzapine. One of the things I would recommend if you have a patient with these symptoms is to go to Fast Facts and search for the symptom they have. It'll walk you through the first-, second-, third-, and fourth-line treatments. At least this way, you don't have to wait for them to see a palliative care physician. You can already start the next line of treatment, and their symptoms are better improved as they go on.

For patients, there's another website I would recommend called Compassion and Support that talks a lot about palliative care and what resources they have to offer for their patients too.

Oncology Data Advisor: Great, those sound like some really helpful resources. Finally, what are some of the opportunities that Heme/Onc Fellows can look for at their institution if they want to get a better understanding of palliative and hospice care?

Dr. Thakur: I think one of the most obvious ones that most residents and fellows would want to do is both an inpatient and an outpatient palliative care rotation. Usually, the majority of trainees will just do the inpatient rotation, where they would get good access to advanced care planning and then also some symptom burden. But if you're really interested in oncology, outpatient palliative care is very, very different, and that's much closer to what I do as an Oncology Fellow with my patients every day. Making sure you have both those options is really important.

Another benefit I have at my institution, because I've been so lucky, is a palliative care unit. This is a pretty rare opportunity that I've had, but there are about 100 palliative care units across the country. As a fellow, if you're nearby one, I would really encourage you to rotate at one of these units. A palliative care unit is basically a palliative care intensive care unit (ICU). What that means is there are patients with very significant symptom burdens who require inpatient admission for titration of opioids or antiemetics or some other really significant symptomatology. By working at one of these units, you'll be able to get a much better understanding of how to take care of these symptoms.

The last rotation that I think all oncology fellows really should do—this was one of my favorite rotations during palliative care—is an outpatient hospice rotation. Unfortunately, as Palliative Care Fellows, you do the majority of rotations inpatient. But having that balance of seeing what a hospice institution is like was really helpful for me to describe hospice to my patients. Especially as an Oncology Fellow, what I've noticed is that most of the time when we discuss hospice, oncologists don't really know what hospice looks like in the home because we're not the ones who are driving house-to-house with different interdisciplinary team members.

Being able to do this rotation and seeing how well patients are taken care of in their home will really help you as an oncologist to reframe what you think of hospice. Oftentimes, oncologists think hospice is giving up on treatment, but when you see what it's like in the home and how much these patients benefit, it's really switching the approach of your treatment from a chemotherapy approach to a very symptom-directed approach. That rotation, I think, is the most valuable rotation any fellow could do.

Oncology Data Advisor: Definitely. This is all really great information, so thank you so much for coming on today and sharing all of it.

Dr. Thakur: Thank you so much for having me. It's been a pleasure to be here with you guys.

About Dr. Thakur

Richa Thakur, MD, is both a Palliative Care Physician and a Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. She graduated from Washington University in St. Louis with a bachelor's in chemistry, medical school at Texas A&M, residency in Internal Medicine, and a fellowship in Palliative Care at Zucker School of Medicine. Her research interests include improving quality of life in patients diagnosed with hematologic malignancies.

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Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.