Dr. Evangelia Kirimis is a medical oncologist for UCLA Health as well as an assistant clinical professor of medicine. She is board certified in internal medicine, hematology and oncology, but a large part of her practice is oncology and breast cancer patients. She graduated from USC Medical School and did her residency and fellowship at UCLA. In her wide-ranging interview, she talks about her role as a medical oncologist. Dr. Kirimis takes the viewer through the entire chemotherapy treatment process, how do you get an infusion and how long will it take? She offers insights on how to prepare for your infusion as well as what to expect from the cumulative effects of chemotherapy. Dr Kirimis talks about how to deal with side effects such as family planning, hair loss, digestive issues, fatigue, chemo brain fog and lymphedema.
I'm Eva Kirimis. I'm a medical oncologist for UCLA. I'm an assistant clinical professor of medicine. I'm board certified in internal medicine, hematology and oncology, but a large part of my practice is oncology and breast cancer patients. I went to USC for medical school and then UCLA for all of my post-training residency and fellowship.
So as a medical oncologist, there's multiple parts to my job. In oncology a lot of what we do are risk assessments so we get a certain amount of information from the pathology and we assess what do we think the person's risk of the cancer potentially causing them problems down the road, whether that's in five years, ten years or long term if you're particularly young. And whenever we consider any treatment modality, including chemotherapy, what we're trying to do is figure out can we reduce that risk and the toxicity related to the chemotherapy worth the potential benefits that somebody's going to get.
The first time I meet a patient, I always meet them in my office because I think it's a little bit less of an intimidating area as opposed to one of the clinical rooms cause they tend to be a lot more sterile. Also it allows me the ability to write everything I say down because undeniably there's no way that anybody could retain the amount of information you have to take in, especially at that point in time. People are anxious; they don't know what's going on; they’re scared.
You really want to try to figure everything out within the first few weeks of your diagnosis so that everything can move accordingly and according to a reasonable timeframe. So I like to walk people through the whole process. You know, I do this all day long but people may not know how do you get the drugs in them; how do I schedule my appointments; who am I going to see; am I going to see you as the physician. So I really literally walk them from beginning to end. This is how you make your appointment; you come into the waiting room; this is what's going to happen; they're going to take you back and they're going to check your blood or they're going to give you the premeditations and go through the pre-medications with them. So that nothing is quite a shock to them.
And then going through what the schedule of the chemotherapy or whatever their treatment plan is because everybody does not receive the same drugs necessarily or the same timing of everything. And then the way side effects come on with chemotherapy is not intuitive. You may not notice anything for several days after the chemo but, if you didn't know that, you can't just assume it. And I think that by allowing people to be empowered to know how to take care of side effects, it helps relieve some of the anxiety. And that, I think, makes chemotherapy a little bit easier as well. Chemotherapy is necessary for any patient that we fear may be little cells that have spread to other parts of the body, whether it be lymph nodes or liver, bones, that we just can't detect.
So it could be the size of the tumor. It could be the type of breast cancer, so for triple negative or HER2 positive, we don't necessarily have to see the lymph nodes being positive to consider treatment, but certainly if lymph nodes are positive, that's another indicator.
At UCLA most of our breast cancer regimens are every three weeks. It can be anywhere between four to six cycles. Again, it depends on the regimen, but I estimate that it will be the better part of a half day for most of the more traditional regimens to somewhere between four to six hours. Nowadays I think it's become much more conventional that there's usually an infusion center or an infusion area close by wherever your treating oncologist is. Some places where it may not be feasible because of logistics may have a local hospital that you go to or a local infusion area where you can get your chemotherapy.
It's hard for people to understand the idea of I feel fine, so why am I making myself sick to theoretically make myself better. The short answer to that is you're trying to prevent complications down the road. It's like buying insurance. For the most part, most chemotherapy is all what we call intravenous or given through the veins with an IV. There's a few exceptions that are usually for people who have more advanced breast cancer where there might be an oral form of the tumor therapy drug, but for the vast majority of people with stage one to stage three breast cancer, we do everything through the vein.
I try to tell people, don't think too far in advance. You know, oftentimes they've already seen the surgeon; they've gotten some information that they're going to go, they're going to get chemotherapy, then they're going to have radiation and they're going to be on this pill, and people have the tendency to get way too far ahead, and it's enough of a battle just to get through that first week of chemo.
A lot of times people fear that whenever you come in to the hospital or office, you're not supposed to eat or drink, and that's the exact opposite of what you should do for chemotherapy. We want you to try to eat normally; stay hydrated; it helps significantly reduce the risk of a lot of the side effects, especially the nausea and vomiting, that people fear the most. Sometimes people fear can I even drive myself to chemo or and we discuss that it's probably going to be perfectly fine, always for the first cycles, cause you don't know what will happen, you want to make sure you have a back-up plan, but for the most part you can drive yourself to and from all of your treatments.
Once people get through the first cycle of treatment, I think it becomes a little bit easier for them to understand because, you know, when you start chemotherapy, it's filled with a lot of misconceptions, the stereotypes, what they've seen on TV. A lot of it also has to do with the individual trusting their doctors and so that's why I can't emphasize enough that you should go
somewhere where you trust the individuals; otherwise, it's hard to buy into the whole chemotherapy thing.
There can be a cumulative effect of the side effects of treatment. So oftentimes by the time you get to, say, the fifth or sixth cycle, I describe it to people as like being a prize fighter. When you get hit the first time, you wake up out of it pretty quickly. By the time you're hit the tenth time, you're a little hazier for a little longer; it takes you a little while; you gotta go to the corner and kind of calm yourself down a little bit. The same thing with chemotherapy, so the first time you get treated, it's not so bad but by the time it gets toward the end, you're feeling the accumulation of the fatigue and all of the other side effects of the treatment.
Usually the day after your chemotherapy you're going to come back to the office for a shot; it's a growth factor that helps keep the immune system up so you're at less risk for infection and other complications that historically would land people in the hospital. There's different versions of it. There's a shorter acting one called Neupogen, which you would do for multiple days, not just one day. And then there's the longer-acting one which is a drug called Neulasta. With the Neulasta your counts don't stay down for as long, so it used to be that your blood counts would stay down for seven days or so before they would start to come up, and it was that window that you'd be at risk for infection. So now that window of opportunity is much, much shorter, so there's a lot less infectious risk with chemotherapy.
Some people may have already completed their childbearing by that point and aren't interested in preserving eggs or embryos or whatnot. Other women haven't even gotten started. So, if having children is important to them, then it's important that they go and meet with a reproductive specialist. They can discuss all of their particular options. Most of this is not covered by insurance, as well, so they have to figure out how important are these factors to them so they can decide in terms of payment.
When you’re in kind of your mid-30's, there's still a very good chance after chemotherapy the odds are still very much in your favor that your ovarian function will come back, but it's not a hundred percent. Also, the literature is not clear, even if your periods do come back and they're regular, are you reproductively still the same? Even once you get through the chemotherapy part of it, somebody who needs to be on endocrine therapy afterwards, that's usually five years at least based off of data, and when you're looking at somebody who’s 35, by the time they get to the stage where they start the hormonal therapy, they're going to be well into their 40's by then, and obviously we know things change in terms of women's reproductive health at that point in time.
Hair is a big issue with women. I can spend almost half my consultation time just discussing hair issues with women. So it generally starts falling out between weeks one to three after your chemotherapy. I would say
most people tend to lean toward weeks two to three. And what's exactly happening is chemotherapy acts on any cells that are rapidly dividing so that’s why a lot of side effects that we see are because they're acting on other cells
besides the cancer cells that grow very rapidly and the hair is one of them. So,
depending on where you are in the hair cycle depends on when your hair is going
to fall out.
Sometimes people can notice a little bit of scalp tenderness right before the hair is going to fall out. And it just doesn't fall out at one time. It kind of starts shedding, and that's why people end up buzzing it because it makes a really big mess for them. But I think the most important thing is that with everything that goes on with chemotherapy, with the surgery or whatnot, you can kind of hide it. It's the hair that you can't hide. It's like it's not even necessarily that they're afraid to show themselves to other people; it's that they don't want the constant reminder every day, every time they look in the mirror, that they’re going to have to go through this difficult time.
As much as people invest in these wigs, they're not comfortable; they're hot; they're itchy. So it can be very, very difficult, and that’s understandable. Unfortunately for a lot of the breast cancer regimens it's par for the course. And what's actually very interesting is a lot of women, once it actually happens, not everybody but the vast majority, it ends up not being as big a deal as they thought it was going to be, and even some after chemotherapy, they actually keep their hair much shorter than they ever had had it before because they realize actually I look pretty good in shorter hairstyles. The hair does come back in differently. Even the first hair that comes out, it's been underneath the scalp, so it's been exposed to the chemotherapy for the last week to months, that hair is not healthy hair so that oftentimes comes out, it's not particularly useful, so sometimes the first hair that comes out people will buzz so they can wait for the new, healthy hair. Sometimes the hair will come out curlier than you used to have bone-straight hair and now it's coming out curly. For most people it will eventually turn back to what your normal hair was but it may take sometime for that.
So the GI tract is another area that's commonly affected by chemo. Again, those cells are constantly replicating so they're more sensitive to chemo. I remind people, imagine when you bite yourself in your cheek, inside your mouth, how quickly it heals; by the next day you don't even recognize that you've injured yourself the day prior because those cells are constantly replicating.
So oftentimes people can develop mouth sores related to the chemotherapy. Sometimes it can be irritation of gastric reflux or irritation in the stomach like gastritis. Obviously people are familiar with the nausea and vomiting that can come with chemotherapy and then sometimes people can just have changes in the way of the motility within the intestine. A lot of our
medications close down the motility so you get very constipated easily, not just from the chemo but a lot of supportive medications, the nausea, the steroids and whatnot, and then some people may have other affects from the chemo that lead
It is true we have many good medications to help treat each of these different kind of areas, so most people should be able to be comfortable during chemotherapy for their GI effects. There's not really nowadays much reason for people to be uncomfortable with the GI side effects.
Fatigue is very, very common when you're undergoing all of the cancer treatment but particularly chemotherapy. So you have to remember most patients, by the time they're starting chemotherapy, they've already been through surgery. They've already had the ups and downs of recovering from surgery and that’s taking a little bit of a toll on the body. You tend to be told by your surgeon you’re not supposed to be exercising or lifting or doing things and so muscles start to already atrophy. Then you go into the chemotherapy phase and obviously you have all of these side effects to deal with, which, you know, imagine you have the flu for one day and the next day you're exhausted. Imagine just consistently having flu symptoms over the course of several months. That takes its toll on the body.
You kind of go down into a low and then you recover from chemotherapy in that last week, but your recovery never goes back up to a hundred percent. So with every cycle, you're the first one may get up to 90, the next one you'll get up to 80, the next one you're up to 70, so you're accumulating that fatigue level as you go on. And then sometimes people can become anemic, which is when their red blood cells drop, and our red blood cells help us get oxygen around to our body, so if we have less red blood cells, our oxygen doesn’t as efficiently get to our body and it can make it harder for us to get around.
We oftentimes will tolerate it to a certain point. If it gets too low, then we have to consider things like blood transfusions or if all the counts are too low whether we need to make adjustments in the dosage of the chemotherapy.
Exercise is huge. There have been studies that have shown that people who are able to engage in exercise throughout chemo, tend to do better after chemo than those that don't. Obviously there's a little selection bias because if you were able to exercise during chemo, well, obviously you would probably do better afterwards, too. But I've seen it even in patients who, for the first couple of cycles, did not exercise and then they tried to incorporate it later on and it really did make those cycles go a little bit more smoothly.
So chemo brain is a very nonspecific term. It's never been very well defined, but it's interesting that women will kind of routinely mention the same thing; that their attention isn't what it used to be; their memory isn't what it used to be. You know, women who tend to be very good multi-taskers, while they're in chemotherapy due to the effects of what is considered chemo brain. They feel like they can't multi-task the way that they used to. We don't know why certain people are more predisposed to it, but there are studies looking at are there certain blood markers, inflammatory markers, that may help us identify who's higher risk for it so that maybe we can identify those patients and prepare them for the possibility.
We don't talk about sexual dysfunction and cancer a whole lot, but I think part of it is that you don't know how important it is for any particular couple. You know, for some it's a bigger deal than others. I think it's important that patients feel comfortable to bring these things up, as well. One of the major things is that women, as they are undergoing chemotherapy, don't feel as attractive; they're losing their hair; they're gaining weight; they're tired; so they’re not necessarily in the mood, but at the same time a large number of them carry this guilt that they're not satisfying their partner. They feel sorry for their mate because they're not at the point that they want to engage in sex and it's kind of a difficult place for them to be in cause they really don't want to, but they feel guilty and they're justified in not wanting to.
We know that women who are pre-menopausal, the ovaries can get affected, so for all intents and purposes they're post-menopausal throughout chemotherapy. They have less estrogen; it affects their libido anyway. Many women will complain of dryness; it can be very painful for them to engage in intercourse. There's things that they can try to do, lubricants, moisturizers, stuff like that. It really depends again on the individual, so the pre-menopausal patients down the road, their ovaries kick back in; and the estrogen goes back; and things kind of normalize again. Libidos tend to improve and they don't seem to have as many concerns in that regard. Post-menopausal women that are on the anti-hormonal or endocrine therapy, it's a common issue for a lot of them because some of them do cause even further dryness down in the vaginal area.
So that's how the era of oncology has changed is that our nausea medications are so much better so people are not as uncomfortable with nausea; they're not dry heaving and vomiting all the time; and so they're able to eat a lot more regularly so that they're maintaining their calories. They're less active so obviously the less exercise the pounds do tend to start to come on a lot more easily. If they were pre-menopausal before the chemotherapy, they are oftentimes if not permanently temporarily pushed into menopause and once you move into menopause the weight comes on a lot easier and comes off a lot harder. And then when you add in a lot of the hormonal manipulations that we do with the endocrine therapy for certain patients with breast cancer, that throws off the kind of estrogen access a little bit, and some of those medications, you’re prone to kind of putting on weight with those medications, as well.
Neuropathy is where the chemo affects the very fine nerves in the tips of the fingers and the toes. They oftentimes will feel like a tingling or a numbness. Sometimes it can be painful in its most severe degrees. We do monitor it so oftentimes we're asking how are the fingers and toes. We do have to accept a little bit of it with some of our chemotherapy, but the important part is trying to make sure it's not going to long-term impact the patient. Nerves are not resilient, so when you damage them too much, they don't come back.
People who already have a predisposition for neuropathy; let's say you're a diabetic and you already have a little bit of neuropathy or you have back issues that lead to lower-extremity neuropathy, you may get more of the symptoms cause your nerves have already been primed or injured beforehand, but it's very nonspecific.
Once you finish the chemotherapy, the neuropathy may improve a little bit but it may not go back all the way to a hundred percent normal again, so that's why we have to watch it very closely because if we cause too much dysfunction, you may not get that function back.
So in terms of depression and anxiety with breast cancer management, it's not uncommon. Maybe some of them will admit that they're depressed. I’m just meeting the person. I don't know what their base line is. I don't know how they're coping with things at home. So it's not uncommon for me to add anxiety medication. There's one in particular that I give. A lot of individuals it's also very good for nausea should they need it in the chemotherapy phase one, it helps calm their nerves; it helps them sleep at night, which also helps them in terms of other symptoms because they do sleep better; you feel better; and then it potentially help with the nausea, as well.
Oftentimes patients, especially at the very end when you think when you think they'd be the happiest to be done with chemo, that can actually be the most difficult time of anxiety and depression because when they were in treatment they were in action; they were doing something; they were beating it. And now suddenly they're not doing anything anymore, and people are telling them, well, now we’ve done everything we can; we're just going to watch and wait; and that can be very difficult to deal with and unsatisfying, so explaining to people, listen, you've done everything that you can; just like in life there's no
certainties; whatever you can control you've already controlled; but now it’s trying to get them to live more in the moment and living a regular life again. So that transition can be very difficult for some people. And it can be very, very helpful for them to even just go see a psychologist or a psychiatrist and talk about some of the things that are that they've been kind of holding back, and that helps release the floodgates a little bit and then we can decide if we need to anything more.
So in terms of dealing with children, it's oftentimes people are at a big loss; they don't know what to do; they don't want to scare their children, particularly the young ones. But I really do believe you have to kind of be honest with them; they're living in the house with you; they know something is going on, whether you're saying the words or not, and I find that most people feel that with their children they eventually figure something is going on. So obviously everything has to be age appropriate; that you don't necessarily give them the same amount of details to a five-year-old as you would to a 13-year-old. But a lot
of it is just keeping calm yourself.
Teenagers obviously get a bigger idea of what's going on, the term cancer was associated with somebody else that the child knew who had died from cancer and so they put the two and two together. So, again, it's sitting down, explaining what the differences are. At a lot of cancer centers there are people specifically trained to help you deal with your children. And I think it's very valuable that other family members be there or caregivers. One, because it’s another set of ears, and then, two, so the people closest to the individual know what's going on and can anticipate the issues and help the person when they may
not be able to take care of themselves.
I think that one of the common things that a lot of cancer patients deal with is, you know, the family has been supportive for a very long time and now when it comes time for that last treatment, the family is like, oh, good, we’re done. But the patient still has to recover from all the accumulation of side effects and getting to feel normal. So it's helping the family understand that it doesn’t end with the last chemo treatment, this is going to be an ongoing saga for sometime because it's almost like PTSD. You're not going to go to war and come back and be exactly the same person. It's the same thing when you get cancer. You get diagnosed with cancer, you can't expect that, oh, I'm done with the treatment, now I'm exactly the same person again. So it's helping the patient recognize that, as well as the family recognize that.
So it's actually a very exciting time in oncology, particularly in breast cancer management. Where we're heading in terms of oncology is trying to figure out if we can have what we call more smart bombs, meaning that you know exactly the pathway that drives the growth of the cancer cell and you develop a drug that specifically targets that pathway, which decreases the residual damage. You know, chemotherapy is more kind of like a nuclear bomb and we’re trying to create smarter bombs. And so we already have, you know, two main areas of targeted therapy in breast cancer so that endocrine therapy that we give for the hormone positive breast cancer and then we have agents such as herceptin and a lot of residual drugs that have come after herceptin that targets the HER2 positive breast cancers. And they revolutionize breast cancer management in those two subsets.
Hopefully down the road, even if we're not able to eliminate chemotherapy completely, we can help reduce the need potentially or less chemotherapy along the way cause really what people worry about the most with cancer. Really what people worry about with cancer management is the toxicity that comes with it, the long-term complications of it. So if you can have these targeted therapies that a lot less short-term and long-term side effects, it will be much easier for all of these patients.
In terms of life after breast cancer, remember that the vast majority of people end up doing very well long term after their treatment for breast cancer, so the odds are very much in your favor.