Ethics of Ongoing Cancer Care for Patients Making Risky Decisions

Abstract

A 31-year-old woman in excellent health presents to her gynecologist with a right breast mass. Mammography and ultrasound confirm a 3-cm suspicious lesion, and biopsy demonstrates high-grade endocrine receptor and human epidermal growth factor receptor 2-negative invasive ductal carcinoma. After discussion of standard therapeutic options with a multidisciplinary oncology team, the patient agrees to neoadjuvant chemotherapy with a plan for subsequent breast-conserving surgery if possible.The patient is treated with neoadjuvant dose-dense doxorubicin and cyclophosphomide followed by paclitaxel. She tolerates chemotherapy well, and the mass shrinks to the point that it is undetectable on physical examination. After therapy, there is no evidence of the mass by breast magnetic resonance imaging, indicating a clinical complete response. As planned, she is then referred back to surgery.Although the importance of surgery was explained at initial consultation and subsequent visits, the patient now expresses her intent to forgo surgery and use natural methods to prevent the return of cancer. The potential for residual tumor, limitations of imaging and examination to detect microscopic disease, and the potential life-threatening consequences of incomplete therapy are carefully explained. The patient seems to understand the recommendations and concerns of her physicians. However, she explains that she has found an alternative through the Internet and has met with an herbalist who advertises a more holistic approach. She provides her physicians with correspondence indicating that surgery is viewed as one option, but an alternative involving herbs and supplements can restore balance to the body and prevent recurrence of her cancer. Furthermore, the herbalist has recommended that the patient undergo a battery of laboratory tests, claiming they will help monitor her neuroendocrine terrain and optimize her herbal therapy. The herbalist also recommends indefinite breast imaging studies, including an ultrasound once every 3 months and magnetic resonance imaging once every 6 months to promote early detection of any recurrence. Despite further discussion, the patient continues to refuse surgery and requests that the medical oncologist order the tests recommended by the herbalist and correspond with the herbalist regularly regarding her care and test results.The oncologist wants to help the young woman and is highly worried that she is placing her life unnecessarily at risk through this course of action. Her physicians are unsure of how they should proceed.

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Let’s Talk About Those Herbs You Are Taking: Ethical Considerations for Communication With Patients With Cancer About Complementary and Alternative Medicine

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