The editorial board of AAHPM Quarterly received a letter to the editor regarding the “Let’s Think About It Again” column in the Winter 2020 edition.
The content of this column was framed around a clinical case of a patient with small-cell lung cancer and active heroin intravenous drug use (IVDU), with the intention of bringing to light the complex issues surrounding the co-management of cancer and active substance use disorder (SUD). As is typical for this column, two opposing views were presented in a point-counterpoint format, acknowledging that the management of a particular patient is a nuanced, individualized discussion of the risk/benefit ratio and likely borrows from the themes in both the point and counterpoint. Read the full Let’s Think About It Column.
The authors of the letter voiced concern about the counterpoint arguing against immediate administration of myelosuppressive chemotherapy in the setting of active IVDU given the inherent risk of iatrogenesis (such as neutropenic sepsis or endocarditis), which may outweigh the short-term potential benefits of chemotherapy. The authors of the letter felt that the counterpoint argument could dehumanize persons with SUD and, therefore, the column should be redacted to prevent perceived harm to our professional community and to patients.
Although the letter writers presented many valid points and concerns in their letter, the editorial board declined to redact the column, recognizing the importance of ongoing dialogue in what is an admittedly difficult clinical situation and highlighting the paucity of national guidelines to guide shared decision making. Instead, we extended an invitation to the letter writers to print the letter, in its entirety, to create a forum to ensure that their views are heard and to further this crucial discussion. Read the full text of the letter to the editor.
The editorial board recognizes the importance of respecting all persons, especially vulnerable populations such as those suffering from SUD. In using this column, accessible to our diverse membership, to highlight the tension between offering life-sustaining chemotherapy and minimizing iatrogenic risks from comorbid SUD and cancer, the board aims to elevate the importance of this conversation and encourage ongoing work to ensure that all persons with SUD receive the best care possible.
We acknowledge the importance of the principles articulated by the letter writers, namely 1) the importance of combatting stigma surrounding SUD and ensuring equitable access to disease-directed care for this vulnerable population; 2) the need to acknowledge the importance of recognizing SUD as a treatable disease; 3) the thorough consideration of all lifesaving therapies through shared decision making; 4) the use of trauma-informed care principles; and 5) the use of harm-reduction strategies. We feel that it is precisely because of these principles, and our unequivocal support for optimal treatment of both SUD and cancer, that an individualized approach to patient care must consider both perspectives articulated in the Winter 2020 “Let’s Think About It Again.”
Furthermore, we also recognize that the clinical care of patients with SUD is more nuanced than a simple point-counterpoint article can fully capture, and acknowledge that the balance of the ethical principles of beneficence and nonmaleficence are held in tension when considering myelosuppressive chemotherapy in this patient population. For this reason, it is important to recognize the potential for harm both from administration of myelosuppressive chemotherapy as well as from the withholding of said therapy. As is central to the philosophy of palliative care, the nuance and complexity of this situation merits a frank discussion with the patient and their family in partnership with the patient, family, and a multidisciplinary team of oncology, palliative care, and addiction medicine professionals, using the principles of shared decision-making. Through this method, a prioritization and sequencing of treatments can be tailored to meet the values, preferences, and priorities of patients with SUD and cancer. Undoubtedly, such a multidisciplinary approach will lead to some patients for whom the risk of chemotherapy will be greater than the benefit in light of active IVDU. For such patients at highest risk of life-threatening complications from SUD, the team, patient, and family may prioritize SUD treatment to improve the risk/benefit ratio of future cancer-directed therapies.
To be clear: neither the editorial board nor the Academy is proposing withholding life prolonging cancer-directed treatments from patients with SUD who would benefit from them with an acceptably low risk of harm. The board does, however, acknowledge that there are many treatable comorbid diseases, including SUD, that must be treated concurrently with, or in advance of, cancer to prioritize beneficence and minimize the chance of iatrogenic harm.
Finally, we consider a cornerstone of palliative care to be the inherent value of open and honest dialogue within the difficult spaces we all occupy as part of our care and advocacy for seriously ill patients. The purpose of the “Let’s Think About It Again” column is to highlight these tensions, and to encourage discussion about the many challenges presented to clinicians in hospice and palliative care. This case highlights the utility of carefully considering the risks and benefits of myelosuppressive therapies in vulnerable populations for whom exacerbation of comorbid treatable conditions may increase their risk for morbidity and mortality. We thank the letter writers for contributing to this dialogue, and we thank you for furthering it here.
We want to hear from you; please continue the discussion below or on AAHPM Connect.
Disclaimer: The purpose of this post is to encourage discussion about the many challenges presented to clinicians in hospice and palliative care. The viewpoints presented here and on AAHPM Connect should not be construed as clinical advice and do not necessarily represent a comprehensive analysis of a clinical situation or the opinions of the American Academy of Hospice and Palliative Medicine. Please post with kindness and courtesy for your fellow clinicians.