Let's Think About It Again

Chemotherapy for a Patient with SUD

Case Study

Mr. Y. is a 45-year-old male who recently was diagnosed with extensive-stage small cell lung cancer (SCLC) and struggles with severe and ongoing substance use disorder (SUD) and regularly takes heroin. He presented to his oncologist, who offered him aggressive chemotherapy with the hope of stabilizing the terminal disease, potentially for months. The oncologist also referred Mr. Y. to an outpatient Suboxone^® clinic to address his ongoing SUD.

The patient agreed to but did not follow the plan as intended, and later presented to an emergency department after a heroin overdose. The patient was revived with naloxone and fully recovered.

Mr. Y. comes to the outpatient oncology clinic a few days later for follow-up. He would like to proceed with chemotherapy but not taking Suboxone and states he can manage his heroin use on his own. He also has a history of longstanding depression and recently became homeless after his son told him to move out following the overdose episode. Other members of the interdisciplinary care team have been consulted about the many issues affecting Mr. Y. and his care, such as the need for safe housing.

Should Mr. Y. be offered chemotherapy if he does not receive appropriate care for his ongoing SUD?

Point: Monika Holbein, MD, assistant professor of medicine, West Virginia University

SCLC is an extremely aggressive cancer that is highly susceptible to the chemotherapy regimen of etoposide and carboplatin. In addition, there is a newly approved immunotherapy that has shown benefit for a subset of patients that could be considered. Given that his prognosis would be less than 1 month without any treatment, Mr. Y. should start treatment immediately.

His SUD should be considered a complicating factor to treatment and not an absolute counter indication. Mr. Y. has not started treatment, so there is no knowledge of his motivation to complete treatment. He also has not yet had the opportunity to benefit from the multidisciplinary nature of cancer treatment, including, but not limited to, social work, oncology, nutrition, palliative care, and radiation oncology.

Unless Mr. Y. is actively engaged in SUD treatment, he likely will continue to use heroin. Using precautions at this point, such as a naloxone rescue inhaler with extensive education for Mr. Y. and his close contacts, will help mitigate the risk of overdose. It is important to practice awareness when prescribing him medications, avoiding benzodiazepines and opioids.

Mr. Y. does not have stable housing after his son asked him to leave. We do not have more information on his support system. Family relationships frequently are complicated when SUD is involved. We need more information on how to best support this family and how to approach Mr. Y.'s healthcare needs prior to passing judgment. There are housing opportunities that may be better suited to this patient's current needs than his son's home.

The ethical considerations of not treating a patient because of a medical condition remain. If Mr. Y. had uncontrolled type 2 diabetes, the question of whether to treat the cancer would not arise. There is an obligation to offer treatment for cancer in Mr. Y. because it would improve his quality of life as well as his quantity.

Counterpoint: Ellen Fulp, PharmD MSPC BCGP, director of pharmacy education at AvaCare, Inc.

Respecting autonomy is a cornerstone of supportive care for seriously ill patients. However, respecting patient preferences does not excuse clinicians from guiding shared decision making and weighing the risks and benefits of treatment options.

Extensive-stage SCLC initially is treated with a platinum-etoposide–based chemotherapy regimen. Commonly experienced adverse effects include nausea, oral mucositis, decreased immune function, pain, neurotoxicity, extravasation, and end organ damage.

Anticipated adverse effects associated with chemotherapy will require additional therapies, which, like chemotherapy, require that the treatment plan be followed to be successful. The long- and short-term effects of continued heroin use compound chemotherapy's adverse effects. Moreover, continued heroin use may prevent Mr. Y. from successfully completing chemotherapy and the medication plan used to offset chemotherapy-induced adverse effects. Mr. Y. displays behaviors associated with self-titration, which could be deadly if he progresses to oral chemotherapy, not to mention oral opioid therapy. Without lifestyle changes and social support at home, Mr. Y. is not likely to tolerate or be able to follow a chemotherapy regimen as prescribed.

Eliminating chemotherapy as part of Mr. Y.'s treatment initially seems cruel. However, as clinicians, it is our professional responsibility to prescribe and design regimens that offer relief of suffering without undue harms and risks. Allowing Mr. Y. to select and receive chemotherapy under the present conditions goes against not only our professional obligations, but also the very principles of palliative care.

Ethically, we must recommend against chemotherapy in this case. It is more likely to cause harm without transient or sustained benefits. As noted with certain other life-prolonging interventions, including bariatric surgery and organ transplant, patients who do not make lifestyle modifications are at high risk for relapse and often do not follow the treatment plan as prescribed.

For justice to be preserved, Mr. Y. should receive the same care we offer every patient we serve. This individualized care must include working together and considering patient circumstances to balance risks with expected outcomes based on patient and medication characteristics. Although rational prescribing dictates that chemotherapy is not appropriate here, palliative care, focusing on symptom resolution and the relief of suffering, always is appropriate for patients diagnosed with extensive-stage SCLC.

The purpose of this column is to encourage discussion about the many challenges presented to clinicians in hospice and palliative care. The viewpoints presented here do not necessarily represent a comprehensive analysis of the issue or the opinions of the authors or AAHPM.

We want to hear from you. Read the Quarterly Editorial Board's response to a letter to the editor and continue this discussion online at connect.aahpm.org.

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