New Treatments Offer Solace for Palliative Patients on Louisiana Medical News

New Treatments Offer Solace for Palliative Patients

By: LISA HANCHEY

Dr. Luis Meza

Over the years, patients at the end stages of life were faced with few options. Most were treated with pain killers and sedatives to ease their pain and increase their comfort. But, new treatments offer options that relieve symptoms — and even prolong life.

The goal of palliative care is to improve the quality or lengthen the life of terminally ill patients. In Louisiana, cancer is the second leading cause of death behind heart disease. According to the Louisiana Tumor Registry publication Cancer in Louisiana, 2000-2004 Volume 22, the most frequent causes of cancer mortalities in males were lung, colon and rectum, and prostate. In females, the most common cancer deaths were from lung, breast, and colon and rectum.

One of the newest devices used in the palliative care of cancer patients is the CyberKnife® Robotic Radiosurgery System. This system uses x-ray image cameras and computer technology to pinpoint tumors. Once the malignant mass is targeted, the CyberKnife's robotic arm accurately delivers 1,200 or more concentrated beams of radiation to the malignancy from multiple positions and angles, without damaging healthy surrounding tissue.

Unlike conventional radiation in which patients must remain very still, the CyberKnife continually corrects for any patient movement during the treatment. The standard stereotactic technique, the Gamma Knife, requires the patient to have a metal frame bolted to the skull to immobilize the body during the imaging and radiation procedures. CyberKnife eliminates this long, uncomfortable process.

Medical oncologist Dr. Luis Meza of Lafayette, La. has been involved in palliative care throughout his 34 years of practice. During the course of his medical career, he has used various forms of treatment to alleviate the symptoms of his critically ill cancer patients, including chemotherapy, radiation therapy, pain killers, sedatives, analgesics and — over the last year — CyberKnife. He has employed this new technique to cure patients, improve symptoms, prevent seizures or headaches, and even lengthen life. In the Acadiana area, a group of doctors, including neurosurgeons, general surgeons, surgical oncologists and, most recently, medical oncologists, have used the CyberKnife to treat patients.

A common indication for CyberKnife is brain metastasis, or the spread of cancer into the brain. Oncologists are now beginning to expand treatment to extracranial areas. Meza has used the device for treatment of solidary lesions of the lung, liver and spine. CyberKnife is typically indicated for localized tumors that are relatively small, numbering no more than three.

The most commonly targeted symptom with CyberKnife is pain. "Seventy-five percent of patients with cancer have, at some point, intractable pain that is difficult to manage with just pain killers," Meza reported. "And, they need the addition of a localized treatment to manage pain, stop bleeding, or decrease the size of the mass in order to decrease pain."

But, Meza emphasizes that palliative care does not necessarily mean that the end of a patient's life is near. "Palliative care doesn't mean we are not ambitious to cure people, or at least to have a curative intent," he said. "I think that I am ambitious enough that I am trying to cure whenever I can. If I can't do that, then I try to go for the next best thing, which is palliation, or improvement of symptoms or lengthening life."

Over the last year, Meza has used the CyberKnife to treat about 35 to 40 patients. "What I'm finding is that patients are beginning to ask for this new technology, because they don't want to undergo a big surgery," he said.

Patients usually require about five treatments with the Cyberknife. Each session ranges from 30 to 90 minutes. Meza finds that the side effects from this system are usually less than with other modalities of treatment.

Meza reports that an increasing number of medical oncologists across the state are making inquiries about CyberKnife as a treatment option for their patients. "I think all medical oncologists are ambitious enough to try and make a serious effort to cure," he opined. "Unfortunately, more often we find ourselves in the palliative role. The reality is there. And, the thing that might happen to us when we are confronting our patients is that we may accomplish something with chemotherapy, and then there is one little isolated area where we are trying to figure out what to do with it — do we attack it with a knife, CyberKnife, radiofrequency ablation or freezing the tumor? There are so many ways to deal with localized treatment. So, we'll look at the most effective, and the least invasive way of treating those solidary tumors."

Palliative Care a Rewarding Experience for Physicians

As physicians retire, more and more are discovering palliative care as a rewarding way to continue treating patients. One of these is Dr. Robert Rivet, a neurosurgeon who practiced in Lafayette, La. from 1968 to 2001. Since 2001, he has served as Medical Director of Hospice of Acadiana.

Before undergoing open heart surgery and having a series of strokes, Rivet had never considered early retirement. But, these severe health problems forced him to make a life change. While recovering at Lafayette General Medical Center from a serious procedure, he was approached by a nurse, Marlene Foreman, who asked him, "What are you going to do now?" Rivet was at a loss as to a response. "She suggested hospice," he recalls.

Soon afterwards, Rivet resumed his daily routine of going to mass at 6:20 a.m. By coincidence, Dr. Bill Smith, then-Medical Director of Hospice of Acadiana, also attended this mass. One day, Smith started talking to Rivet about hospice, and invited Rivet to an Interdisciplinary Group (IDG) meeting held every Wednesday. Rivet went the next day, and was instantly hooked.

After Smith died, Rivet assumed the position as Medical Director of Hospice of Acadiana. This program serves the parishes of Acadia, Evangeline, Iberia, Jefferson Davis, Lafayette, St. Landry, St. Martin, St. Mary and Vermilion. Four years ago, the Acadiana chapter launched a satellite program in Houma —Bayou Region Hospice.

HOA now has 26 volunteer physicians in Acadiana and three in Houma. These doctors come from 14 medical specialties, including family practice, surgery, cardiology, ophthalmology, obstetrics/gynecology, otolaryngology, psychiatry and anesthesiology. Physicians are available to staff 24 hours a day, seven days a week.

As Medical Director, Rivet works five days a week from 8 a.m. to noon, and more hours as needed. His daily activities consist of signing death certificates and filling out applications for Medicare recertification. After his shift, he visits hospice patients at Lafayette General Medical Center. During his tenure, he has seen over 100 patients at home, always accompanied by a hospice nurse. He also attends IDG meetings each week, and recruits the volunteer physicians. "He is doing a great job," reported Executive Director Nelson Waguespack, who has been with HOA since its inception in 1984. "The physicians are quite receptive."

Rivet says that he has even turned down physicians who wanted to volunteer for hospice. If they lack the qualities to make a good hospice practitioner, he does not hesitate to say no. The qualities that he thinks are essential for a hospice physician are a significant amount of spirituality and compassion. "Knowledge is the least important, because we have great nurses who have all of the knowledge required," he said.

Rivet tells other physicians, "Helping a dying patient get closer to God, be pain free and have a peaceful death is as rewarding as saving someone's life."