The Intersection of Palliative Care and Interventional Oncology: An Interview With Sean Tutton, MD

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The 39th Annual Meeting of the Society of Interventional Radiology (SIR) addressed a comprehensive array of clinical issues facing interventional radiologists, including a growing need for training in interventional oncology. Interventional Oncology 360 spoke with Sean Tutton, MD, about palliative care training he obtained at Medical College of Wisconsin in order to improve his interventional oncology practice.

Q: Could you tell us about your interventional oncology practice at your facility?

A: I am a professor of radiology, medicine and surgery at the Medical College of Wisconsin and my area of focus is interventional oncology, spine and musculoskeletal interventions, and palliative care. I just trained in palliative care this past year. We worked with our palliative care team at the college. Wendy Peltier is the director of palliative care there and she helped my partner, Dr. Robert Hieb, and I go through the process of becoming board eligible and board certified in palliative care. 

The genesis of this was that in interventional oncology, when we take care of cancer patients we take care of patients who are suffering and have pain, nausea, vomiting, diarrhea, constipation – all of the symptoms associated with cancer. As an interventionalist, I felt moderately comfortable with those symptoms, but I wanted to become more expert in treating pain and I wanted to understand narcotic management and relief of all suffering that cancer patients go through. 

Training enabled me to have a better handle on the care of my patients. For example, when we treat patients with hepatocellular carcinoma, we use liver-directed therapies including Y-90 and chemoembolization, and postembolization syndrome is one of the classic problems that we deal with after these treatments. The skills needed to help them manage pain, nausea, lack of appetite, and constipation if they are on narcotics are all in the wheelhouse of a palliative care physician. Frankly, they should also be in the wheelhouse of an interventional oncologist and so that is why we decided to become better trained. It has paid off incredibly well for me. I’m able to teach my fellows a lot of these techniques and a lot of strategies in managing these patients, but more importantly palliative care has a philosophy of relief of suffering rather than necessarily curing patients. Many of the patients we see in interventional oncology are not going to be cured by our therapies but we are trying to maximize their quality of life. We want to improve their survival, of course, but it’s really all about quality of life and so that is my focus. 

Q: Can you describe a little about the palliative care sessions offered at SIR?

A: For the first time at the SIR meeting, Dan Brown and the leadership approached us and asked us if we wanted to have a plenary session on palliative care, which I thought was a great opportunity. Dr. Hieb, Dr. Albert Nemcek from Northwestern Memorial Hospital, Dr. Peltier, and I will have a session totally focusing on interventional therapies that are palliative in nature that can help our patients. Dr. Hieb is going to focus on vascular care, I’m going to focus on nerve blocks to relieve pain and also vertebral augmentation to relieve pain in patients who have metastatic disease to their spine with pathologic fractures. Dr. Nemcek will focus on drainage procedures and the management of malignant collections of fluid in either the abdomen or the chest, and Dr. Peltier will give us the broader view of palliative care and how interventional oncology and interventional radiology are really well suited to working in a team with palliative care. 

All cancer therapy should be team based. We all know that it is vitally important. Palliative care is going through an evolution, just as interventional oncology is going through an evolution, so our goals and our missions are very well aligned and I think that we will work very well together in the future.

Q: What are the palliative care therapies that are developing that you find most intriguing right now?

A: We’ve been offering biliary drainage procedures and genitourinary drainage procedures; any of the venting gastrostomies are all procedures that are very much in the palliative care wheelhouse. A lot of patients have obstructive symptoms and we can play a huge role for those patients. We treat them in a minimally invasive way. We often avoid general anesthesia so the drainage procedures including pleural drainage catheters and the abdominal drainage catheters to manage malignant effusion are also very important. 

My own area of expertise is musculoskeletal pain. For pathologic fractures in patients who have renal cell cancer, thyroid cancer, breast cancer, prostate cancer, there’s very good level-1 data that says that if you perform vertebral augmentation, you will help relieve patients’ pain, lower narcotic requirements, and improve patients’ quality of life. In regard to vascular disease, we have lots of patients who are not bypass candidates and we perform minimally invasive interventional techniques to treat chronic limb ischemia, which is very debilitating and can lead to amputation that has high morbidity and mortality. So, our interventions to spare amputation can be palliative and can also increase patients’ survival. As far as evolving therapies, there’s growing interest in bone and soft tissue ablation with cryotherapy, radiofrequency ablation, or microwave ablation. Those therapies have reasonably good data to demonstrate pain relief, reduction in narcotic requirements, and improved quality of life. I think we’ll see a huge growth in those procedures for our cancer patients. 

Q: How do you think palliative care will become part of interventional radiology? Will there be more palliative care training as interventional radiology continues to evolve?

A: I think that some form of palliative care training for our fellows is critical. At the Medical College of Wisconsin, because of our relationship with palliative care, we are having our fellows rotate through palliative care so they round with the service, they sit in on their working sessions, they sit in on the family meetings to talk about goals of care, end of life discussions, and hospice. Our fellows are getting that exposure in a direct way with the palliative service. That cross pollination goes both ways, so our relationship with our palliative care team has educated them on the services and therapies that interventional radiology and interventional oncology can offer palliative patients. I am now being inundated with patients who have very difficult pain syndromes because the service will call me and say, “We have a patient with epigastric pain from pancreatic cancer. Do you think you can do a celiac plexis nerve block?” That’s a perfect example of how we can, in a very minimally invasive way, in a very low-risk way, treat patients’ pain, lower their narcotic needs and risks, improve their quality of life, and reduce the side effects of the narcotics. That’s a very tangible way that I’ve seen the cross pollination really pay off in education of the palliative doctors in what interventional oncologists can offer to their patients. 

I will often go up to the palliative floor, go into the workroom, and ask the palliative physicians, “Who’s on your service?” Often, we’ll already know most of those patients because they’re our patients as well. We can discuss how the patients are doing, whether there’s anything more we can do, and whether there are any tough patients who we want to focus on. 

This team-based approach has driven our referrals up dramatically. Because of my understanding of palliative care, I will see a patient in my clinic who I know is an end-of-life patient or a patient who has an advanced cancer and I can make the palliative care referral earlier. When you make a palliative referral earlier, there’s data that says that you can prolong survival in certain cancers, so again, by working together, we’re actually benefiting the patient tremendously.

Editor’s note: Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Tutton reports consultancy, patents, stock ownership, and reimbursements from Benvenue Medical.

Suggested citation: Ford J. The Intersection of Palliative Care and Interventional Oncology: An Interview With Sean Tutton, MD. Intervent Onc 360. 2014;2(8):E67-E69.