In Uncertain Times, Oncs Are Among the Best at Risk Assessment

Mark A. Lewis, MD


July 14, 2020

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This transcript has been edited for clarity.

This is Mark Lewis. I am the director of gastrointestinal oncology at Intermountain Healthcare in Utah, and I'm a contributor to Medscape.

I was recently privileged to publish a perspective piece in The New England Journal of Medicine, entitled "Between Scylla and Charybdis — Oncologic Decision Making in the Time of Covid-19."

Many people, including my wife, asked, "Why didn't you just say 'between a rock and a hard place'?" I would respond that one of my majors in college was ancient Mediterranean civilizations. I worked really hard to learn ancient Greek, so I'm going to reference Homer when I can. Here, I think it's actually a very apt metaphor.

In The Odyssey, Odysseus is faced with a very difficult decision. "Between Scylla and Charybdis" actually refers to how sailors have to navigate through the Strait of Messina, which is a real strait between Sicily and the Italian mainland.

In Homer's myth, the rocky shoals on one side were represented as a six-headed sea monster that would pluck sailors off a ship; and the other side, Charybdis, was a whirlpool. Ultimately, Odysseus had to make the difficult decision to steer toward Scylla so he would only lose a few sailors rather than taking the whole ship down the whirlpool.

I sort of feel, as oncologists, like we are trying to be the captains of our patients' ships — obviously, never taking away their autonomy and their own leadership, but really trying to guide them and steer them.

On the one hand, we have the acute threat of the coronavirus, and on the other hand, we have the chronic threat of malignancy. We're trying to make decisions now against the clear and present danger of COVID-19 while also anticipating what might happen later on to our patients.

Unfortunately, I envision a bimodal peak where, right now, people who are profoundly immunosuppressed are more vulnerable to the virus and thus might succumb to it. Later, I'm concerned that we might see the mortality of patients whose current cancer treatments have been postponed, deferred, or de-intensified.

I hope that won't happen, but I am deeply concerned that that might come to pass. Unfortunately, we can only do our best to make decisions in the present with the information we have right now.

That's certainly a concern for all of us, but I'd like to remind oncologists that of all the medical specialties, we might be among the most used to doing risk assessments. Often, when we're counseling our patients, we have to balance risk and benefit. We're very adept, I think, at taking statistics or abstract mathematics and applying them in a very personal fashion that doesn't seem too cold or clinical to our patients in guiding them.

I would add that there's a whole new risk calculus now with COVID-19, but this isn't vastly different —just in terms of the thought process — from some of the machinations we were already going through when, say, we were counseling a person who's had a complete resection to undergo adjuvant therapy, which is always the hardest sell.

How do you convince someone who has been told, "We got it all in surgery" to undergo chemo vs someone with metastatic disease, where I think the benefit of the chemo is a little bit more tangible and easier to explain?

I'll point out that it's in that latter group, the patients with metastases, where I've really been very hesitant to completely back off treatment. I have been watching white blood cell counts, particularly absolute lymphocyte counts, like a hawk and trying to guide them through the nadirs of their treatment so we can still keep their cancer, hopefully, at least controlled, while also protecting them from COVID-19.

These are really uncertain times. I just want to get a message of hope and resilience to everyone — my patients, my colleagues in medicine (not just in oncology but in all specialties) — because I don't think there's ever been more of a team effort. Together, we can navigate the strait and try to guide our patients and ourselves between Scylla and Charybdis.

Mark A. Lewis, MD, a cancer survivor, is director of gastrointestinal oncology at Intermountain Healthcare in Salt Lake City, Utah. He has an interest in neuroendocrine tumors, hereditary cancer syndromes, and patient-physician communication.

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