Darrin Godin: Hello and welcome to Talking Hope. I'm your host, Darrin Godin. Our guest today is Dr. Diya Sandhu, a fellowship-trained expert in interventional pain management. Dr. Sandhu focuses on highly personalized care for patients with cancer offering treatments ranging from holistic and natural remedies to advanced procedures such as spinal cord stimulation. In addition to her clinical practice, Dr. Sandhu is noted for her research on managing chronic pain for older adults, women and athletes. She practices at City of Hope, Orange County, Lennar Foundation Cancer Center, the most advanced comprehensive cancer center in Orange County. Thank you for joining us today, Dr. Sandhu and welcome to Talking Hope.
Dr. Diya Sandhu: Thank you so much for having me.
Darrin Godin: Well, let's talk first about this instinctive desire that we all have to help somebody when they're in pain. What are the most important traits to have as a physician who cares for patients every day who are experiencing pain?
Dr. Diya Sandhu: Yeah. That's a great question. I think there are, for me three things that come to mind. The first thing is simple, being a good listener, understanding what type of pain our patient has, how it impacts them, and what their goals are. As a pain management provider, we really develop a close intimate relationship with our patients because pain affects them so deeply, both physically and emotionally. And understanding all of that complexity really starts with listening.
The second thing that comes to mind is being collaborative. Having a team approach. Cancer care, pain management or not should always be a team approach, but especially when we're talking about managing pain, a good pain management provider needs to be able to work together with the oncologist, radiation oncologist, the surgeon, palliative care, etc. And then the last thing that comes to mind is being able to have a comprehensive skill set when it comes to taking care of pain.
Cancer doesn't play by any rules. It can be in any part of the body. It can metastasize anywhere, it can grow, it can change it's dynamic, and it can be very challenging to treat. So as a provider, you need to have a bunch of different tools in your toolbox and you always need to be thinking outside of the box. You need to be creative. And this really helps with patients getting a good result.
Darrin Godin: Having had a family member who experienced a cancer journey and was in a lot of pain, I think pain management is certainly part of compassionate care. I mean that feeling of pain and being in pain, that just changes everything for the patient. So talk to us about what some of those causes of pain are when a patient has cancer?
Dr. Diya Sandhu: Yeah, cancer pain is very complex and it's really a mixed bag of different sources, but we generally talk about two basic types of pain. So one is nociceptive pain or pain from a direct tissue injury, and the second is neuropathic pain or pain from a nerve type injury. And pain can come from the tumor itself. So tumors can grow, they can expand, they can irritate surrounding structures causing pain. And then as well, if the tumor metastasizes to different parts of the body, the same phenomenon can occur in each location of the different metastases.
And then in addition, patients can have pain related to cancer treatments, the radiation, the chemotherapy. These things can cause pain. If a patient needs a surgery for their cancer, they can also have post-operative pain. And then lastly, something that I think is very important is that a lot of patients have pre-existing, non-cancer related pain that often needs to be addressed because it starts to interfere with their cancer journey and their cancer treatments.
A good example of this is if somebody has had a bad back for many years, if they have chronic low back pain and then unfortunately they get cancer and maybe they need a large abdominal surgery to remove that cancer, post-operatively they're going to have a ton of back pain because their core muscles, their abdominal musculature has been disrupted by that surgery. And our core helps to support our back. So then you have a patient trying to recover from a surgery, having post-operative pain, and then also having to deal with their pre-existing low back pain. And then all of it is mixed together and it makes for a very difficult experience in terms of the amount of suffering that they're having.
So we really need to address the patient holistically, looking at things that were affecting them before the cancer and also sources of their cancer related pain.
Darrin Godin: So back to one of the characteristics you mentioned at the top of our time together, you said being a good listener. So really listening and figuring out where these things are coming from and where the pain originates is so important for that patient. How do you go about tailoring a treatment plan to the patient's individual needs? And I'll also add another part to this question, talking about that cross-functional partnership with others in the patient's journey, how do you tailor the plans to make sure that everyone's involved in what you do to treat the patient?
Dr. Diya Sandhu: Yeah, that's a great question. And it comes back to the original part of your statement listening, right? So the first thing that we do when we meet a patient is we take a detailed assessment of the patient's pain. Then I want to know what are their functional goals? What are their cultural preferences? What are their values? What are their goals of care within the realm of their cancer treatment? And based on all of those answers, we build a foundation upon which a comprehensive treatment plan is built. And then when we talk about the building blocks of that treatment plan, we start from the most conservative and then subsequently move our way up to more invasive treatments.
Some of those conservative treatments include things like lifestyle modification, optimizing exercise and nutrition. We also talk about holistic and alternative treatments for managing pain, things like acupuncture massage, physical therapy, occupational therapy, mindfulness. And then once those things have been optimized to the next tier in terms of pain management, we're looking at things like prescription medications for pain, sometimes in office procedures like joint injections or trigger point injections. And if that's still not enough, that's where we talk about more invasive pain procedures like injections or pain interventions.
Those are procedures that are done in the operating room oftentimes. And so based on all of these factors, we bring it back to their oncologist, their radiation oncologist, and make sure that all of the details that we're acquiring and the plan that we're building fits seamlessly into the plan that the oncologist has for them. And how can we work together as a team towards the same goal? But at the end of the day, really each individual patient deserves a very bespoke sort of white glove approach to their pain management. And no two pain management treatment plans are the same because every patient is so unique.
Darrin Godin: Well, City of Hope, as you know, we are top five ranked cancer care in the nation by US News & World Report. That means something for our patients. When they come here, they're receiving the best of the best care that's available. Talk to us about what patients can expect from City of Hope.
Dr. Diya Sandhu: Yeah. Here at City of Hope, we are not simply treating a diagnosis or a scan. We're treating, the whole patient and we're helping them improve their function and quality of life. Something that's unique about our pain management department is that patients are not simply just seen for an injection and sent on their way. They get longitudinal care. We follow patients through survivorship or end of life. Each patient's cancer journey is unique and dynamic, and subsequently, their pain needs are going to constantly be changing. And they need someone who's there who knows them well, that can be with them with every step along the journey.
And then the last thing that sets us apart which is part of what we've mentioned previously, is that really nice seamless integration with the rest of the oncology care team.
Darrin Godin: We have a saying at City of Hope that when we take a patient's hand, we never let go. And it sounds like that's near and dear to your heart as well. You recently treated the first patient at City of Hope nationwide with a drug called QUTENZA. Can you talk to us about that treatment option and how it's benefiting our patients?
Dr. Diya Sandhu: This is such an exciting area for me. QUTENZA is a topical medication that's used for neuropathy. It is applied in the office. It contains capsaicin, which is the chemical that makes chili peppers hot. And when the patch is applied to the skin, the capsaicin starts to affect the nerves that are causing pain in the areas that patients are having pain from neuropathy. It's FDA approved currently for the treatment of post-herpetic neuralgia and painful diabetic neuropathy. But here at City of Hope, many of our patients suffer from something called chemotherapy-induced peripheral neuropathy.
And that is a common side effect of certain chemotherapy drugs such as taxanes and platinum-based chemotherapies. And patients often get symptoms like numbness, tingling, weakness, and usually this affects the hands and the feet the most. QUTENZA is a drug that's being used off-label with growing evidence in the field of chemotherapy-induced peripheral neuropathy. It may be especially beneficial and useful for patients who don't respond to the traditional treatment, which is currently oral medication. Things like gabapentinoids or antidepressants, usually these medications cause unwanted side effects or sometimes they just simply don't work for patients and they don't help to alleviate the amount of suffering that our patients are enduring.
So QUTENZA because it's topical, it's very well tolerated. It doesn't have any significant drug interactions or systemic effects. And so it brings hope of a new treatment to these patients, and it's generally very well tolerated. The main side effect are local site reactions like some skin irritation are burning from the patch application site, but those effects are usually transient and well tolerated. So this is an exciting area of innovation and something new that we are offering for patients suffering from nerve pain.
Darrin Godin: What can be done for a patient when medicine is not enough?
Dr. Diya Sandhu: Yeah. That's a great question because often that's when patients come to see me. It's because a traditional pain medication or a few different pain medications haven't been enough to really get down to the root of their pain. So the first thing to address is lifestyle modification. So optimizing the patient's nutrition, optimizing the patient's exercise, optimizing sleep, checking on their mental health. Are they having emotional distress? All of these things need to be addressed because they affect a patient's physical pain experience. And then we explore supplementing the pain medication with integrative therapies.
We are so fortunate here at City of Hope to offer a multitude of options. So we often supplement oral pain medications with things like acupuncture, massage, music therapy, mindfulness, just to name a few. And then if that's still not enough that's where my expertise comes in, in terms of offering patients a variety of different injections.
And I can talk to you about some examples of those. So the first of which is joint injections. So those involve injecting a medication like local anesthetic or steroid into a joint to help alleviate inflammation or pain. And that's often done for arthritis, chronic joint pain, or sometimes if there's cancer nearby causing pain in the bones or joints. Another type of injection is something called sympathetic blocks. Sympathetic blocks is where we inject an anesthetic near sympathetic nerves. And this is especially useful for patients with cancer that causes pain in the abdomen.
So pain in the epigastric region or the center of the stomach, pain in the lower abdomen, sometimes pelvic pain and even pelvic floor pain. So for patients with gynecologic cancer or rectal cancer, these sympathetic blocks can help to block the nerves that are causing pain from the cancer invasion. Similarly, there's other blocks where we can block nerves that are peripheral or more outside of the body.
Those can be used for things like pain after a mastectomy. And then we also offer a really wide range of different injections for back pain. Some of those include things like facet injections which are injections of steroid and numbing into the little joints of the spine, often affected by arthritis. And then there are also epidural steroid injections, which is where we're placing medication in the epidural space.
Epidural steroid injections can be used for things like herniated discs or sciatica. Also, sometimes cancer can metastasize to the spine and can compress on nerves and mimic nerve pain, like a sciatica type syndrome. And often we can offer an epidural steroid injection to try to help with that nerve pain as well. There's also something called radio frequency ablation, which is a minimally invasive type of technique that uses heat to actually burn down nerves in the spine or joints, and it can actually cause some longer lasting pain relief.
And then lastly, we also offer something called neuromodulation. A good example of neuromodulation is spinal cord stimulation, which is a device that's surgically implanted, and it helps to interrupt pain signals between the spinal cord and the brain. And we often do that for complex back pain, pelvic pain, different types of nerve pain. So there are so many different options for patients that are not responding to oral medication alone.
Darrin Godin: Wow. It's really quite fascinating how many options there are and all the tools you have in your toolbox to help a patient. I just keep going back to this idea of listening. It's so important for patients to talk about what they're experiencing as well because of an expert like you, you can help solve some of those issues if patients will tell you about it. So it's a fascinating work you're doing. We have a quote that is so near and dear to us. In fact, it's behind you on your background there, and it's from one of our early leaders here at City of Hope, and it says, "There is no profit in curing the body if in the process we destroy the soul." How does that resonate with your work? And can addressing emotional or spiritual suffering also be part of pain management?
Dr. Diya Sandhu: Yes, of course. It's so important to get to know your patient and understand what the essence of their soul is. What brings meaning and happiness to their life? Because that essence is what our entire pain management treatment plan is built around. So for example, imagine a patient who's a baker. So their soul or their enriching experience might be that nostalgic smell of their famous cookies filling the kitchen. And that's really what brings them joy, what fills their cup. Or maybe it's a golfer who so desperately wants to return to golf, and then they get to enjoy that really satisfying clink sound that the driver makes when it hits the golf ball just right. And it's like that's their aha moment.
Or maybe it's just being able to chase after their grandkids. These are all things that enrich us, that fill our soul, and that the treatment plan needs to be built towards achieving those goals to preserve someone's soul and make sure that they're having a very high quality of life. So that's very important.
And then when it comes to emotional and spiritual suffering, chronic pain often causes feelings of frustration, sadness, anxiety, or even depression. And if emotional distress isn't adequately addressed, it can worsen the overall experience of the pain and make things harder to manage. So it is just as important, sometimes if not more so than managing the physical pain. And we're so fortunate at City of Hope to have even more resources to help patients with coping. And so some of those are social work, our psychologists, our psychiatrists, mind, body medicine, just to name a few. So we have a whole team to help make sure that patients feel well cared for.
Darrin Godin: The team is phenomenal. And I just have to say those pictures you just painted and some of those examples... I mean, I'm a golfer myself and the smell of the fresh cut grass in the morning and the sounds. If you're in pain and you can't get out there to do those things you love, life doesn't feel as full as it needs to be. So I think what you're saying is so true. That leads me to my next question that we ask all of our guests here on the podcast. And it's asking you, what does the concept of hope mean to you? And I have a feeling where you're going to go with it, but what does the concept of hope mean for you and for your patients?
Dr. Diya Sandhu: For me, hope means being able to see the positive side in any situation and the expectation that things can get better. Bringing hope to our patients, encourages them to persevere, encourages them to be resilient. And specifically in the world of pain management, hope enables patients to feel that there are options to minimize their suffering and discomfort so that they can lead a more fulfilled, a more enriched life. That's really what hope means to me.
Darrin Godin: Thank you so much. What is the message you want to leave our audience with today, Dr. Sandhu.
Dr. Diya Sandhu: Managing pain. It's a very important part of your cancer treatment plan, and there are many options available. So if you feel like your pain is not being adequately managed, please ask your provider what else can be done. Can I be referred to a specialist? Are interventions right for me? It's important to be an advocate for what your personal values are, what your personal take on your pain management should look like, and how it helps you achieve those goals that we discuss, those functional goals that enrich your soul.
Your pain management plans should be specifically tailored to you. It should not be a cookie cutter approach. And then lastly here at City of Hope, the Interventional Pain Service really strives to enhance quality of life through innovative pain techniques, collaborative care, and most importantly, a deep commitment to minimize suffering. And all of this is done while honoring each patient's unique journey through their cancer treatment.
Darrin Godin: Wow. Dr. Sandhu, thank you so much for your expertise that you bring to City of Hope. And I think also our listeners today are probably getting a good sense of who you are as a person, your compassion, and the way you care for your patients. So thank you for all that you bring to City of Hope. And thank you of course for joining us today on Talking Hope. We really appreciate you taking the time to be here with us.
Dr. Diya Sandhu: Thank you so much for having me.
Darrin Godin: City of Hope is top five ranked cancer care in the nation right here in Orange County. In the hands of the nation's leading physicians, scientists, and researchers, you truly do have hope. Visit cityofhope.org/oc for more information or call us at 888-333-HOPE. That's 888-333-4673. I'm Darrin Godin. Thank you for joining us on Talking Hope and we will see you next time.