What’s New in Palliative Care? ASCO 2025 Highlights

I was able to attend the annual ASCO meeting in June 2025. It was lovely to reconnect with so many colleagues. In this month’s Newsletter, I want to share what I consider the most clinically useful updates presented there in the area of  Supportive/Palliative Care. To include as many as possible, I’ll use a “bullet point” format and categorize into the relevant Resource headings I use on my website: Pain & Symptom Management, Communication, and End of Life Care & Bereavement. If you want more information about any of the abstracts discussed below, please email me directly.

Pain and Symptom Management
Cannabis

Cannabis is legal in 37 states and the District of Columbia, and in 3 territories. CBD oil only is allowed in Georgia, Indiana, Kentucky, Iowa, Tennessee, Texas, and Wisconsin. It is fully illegal in Idaho, Kansas, Nebraska, North Carolina, South Carolina and Wyoming.

In 2024, ASCO published a Cannabis guideline (Braun et al. J Clin Oncol 42:1575-1593).

Important take home points from this Guideline and the 2025 abstracts reviewed in an educational session include:

• There is no negative survival effect for patients who used cannabis along with Immune checkpoint inhibitors
  • There is no evidence that cannabis has an anti-tumor effect; it is not antineoplastic
  • In patients with locally advanced or metastatic lung cancer, CBD may improve pain, insomnia, and dyspnea.
  • Clinicians should keep the dose of CBD <300 mg/day to avoid elevating the patient’s LFTs
  • Cannabis overdose is characterized by ataxia/falls, anxiety/paranoia, orthostatic hypotension causing dizziness/falls
  • Given the prevalence of patient use of cannabis products and the number of significant drug interactions, the panel urged that cannabis use be assessed in the EHR in the same detail as tobacco use
    • Contraindications: warfarin, amiodarone, levothyroxine, clobazam, lamotrigine, and valproate
    • Decreased appetite with Adderal; increased diarrhea with metformin and omeprazole; increased MVAs with psilocybin
    • Doubled side effects with antipsychotics, opioids, benzodiazepines, antidepressants, antihistamines, alcohol, kava, melatonin, and St. John’s wort.

Hot flashes: Elinzanetant is an option

• Elinzanetant, a dual neurokinin-1 and 3 receptor antagonist, is effective for hot flashes (Abstr 508; Cardoso et al doi: 10.1056/NEJMoa2415566). The neurokinin-1 inhibitors (e.g. aprepitant, fosaprepitant) are widely used to prevent CINV. Given that Neurokinin B in the hypothalamus is responsible for the body’s heat regulation, it is not surprising that an inhibitor of these neurokinins can block hot flashes.
  • May be useful for patients on tamoxifen, who cannot use paroxetine, or those with side effects from gabapentin or venlafaxine. Oxybutinin has shown activity for hot flashes in men on Androgen Deprivation Therapy.
  • Starting dose: 120 mg daily; may increase to 160 mg daily

Is local (vaginal) estrogen therapy safe for breast cancer survivors:  YES!

• Vaginal estrogen does not decrease survival of breast cancer patients (Abstr 578).

Can anything prevent chemo-induced peripheral neuropathy (CIPN)? Limb cooling, maybe

• Duloxetine didn’t work better than placebo (Abstr 12010), but there was a very high placebo response—66%, so that would be hard to beat! Especially since the adherence rate for placebos was 66% while that for duloxetine 30 mg was only 44% and for 60 mg was only 50%.
• Limb cooling was not effective (Takano, Abstr 12002), but the limbs were not cooled as much as in the studies where it was effective (Ran et al Support Care Cancer2025; Michel LL et al, JAMA Oncology 2025)). So, the jury is out.

Preventing radiation-induced nausea and vomiting: Use Ondansetron with Olanzapine

• Patients who need radiation to the abdomen or pelvis can suffer from severe nausea and vomiting. 80% of the body’s serotonin is in the gut, so ondansetron is used routinely to block the serotonin receptors in the brain’s fourth ventricle and thereby prevent vomiting. Substance-P is also released from the gut with radiation; I’ve used aprepitant for a patient who needed radiation to stop his gastric bleeding, but who was not responding to even high doses of ondansetron.
• Radiation-induced nausea has been particularly difficult to control with ondansetron alone.  Patients receiving ondansetron (4mg bid) and placebo in this study had only 16.3% complete relief from nausea while those getting ondansetron with olanzapine (5 mg daily) had 86% complete relief and 96% (vs 75%) complete relief from vomiting (Abstr 12001).   
• Patients in the olanzapine arm had more sleep, better appetite, and better QoL scores, but more often had Grade 1 drowsiness, dysarthria and hypotension. 

Using VR for patients with hematologic malignancies: Promising

• Patients with hematologic malignancies undergo repeated bone marrow biopsies, the discomfort of which usually requires an opioid along with a benzodiazepine (to promote forgetting the experience entirely!). A systematic review showed that while there was no difference in 3 studies, in two, VR significantly reduced pain and anxiety (Abstr 12075)
• A pilot study (Abstr 1504) indicated that VR may also be helpful for psychological well-being of patients undergoing HSCT. 60% of those randomized to five self-directed modules during the hospitalization for HSCT were able to complete all 5 modules, and at 4 weeks, they had less anxiety, better QoL and self-efficacy, less depression and less PTSD than controls.

Communication
Send condolence letters

• I was pleased to learn that a physician or their office simply sending a condolence letter offering a post-mortem consultation to bereaved relatives was very effective in reducing grief at the patient’s death. It also relieved grief, anxiety and depression 3 months later and anxiety and grief even 6 months later (Abstr 12028). This was true despite only 5% of those receiving the offer accepting the post-mortem consultation.

Grief and End of Life Care
Factors leading to Burnout

• A 2019-2021 survey of 15 academic medicine centers reported contributors to burnout (Abstr 9005).  The most important factors were, according to Dr. Ligibel, the first author, personal fulfillment; whether the individual’s work environment had value alignment, peer support, and supportive leadership behaviors; and working together in teams.  In addition, ASCO published a 2025 guideline (Winer et al. JCO 2025;43:2017-23) for academic medical oncology departments, urging a balance between research and clinical workloads.
• My article “Grief’s hidden role in oncologists’ compassion fatigue and burnout”, in Targeted Oncology (alsopublished in the June 16, 2025 ACCC Oncology Issues (vol 40; number 3), discusses how two unrecognized issues, disenfranchised grief and countertransference, contribute to oncology clinicians’ compassion fatigue and burnout. Arnold et al, in Navigating communication with seriously ill patients, 2^nd ed (Cambridge University Press, 2024), also discuss the implications of unrecognized countertransference to patient care.

Additional resources in all the areas covered here appear on this website under Resources.