Saving a Life: Balancing Risks, Harms, and Benefits in Palliative Care

DOI: 10.1200/JCO.2013.53.9338 The letter from the hospital’s Office of Development was marked “Confidential.” No, we had not been offered the $10 million endowment I had been hoping for. But the letter, signed by the vice president of Development, was to inform me of a gift of $100 in my honor from a grateful patient. It read: “You are my special angel. Thank you for saving my life.” The donor was a woman in her sixties with metastatic breast cancer. She had been a patient of mine for only a few months. She was referred by her breast oncologist for assistance with pain management, and I had seen her in the clinic on only a handful of occasions. Hers was an unusual cancer story, at least in my experience. She had been diagnosed with triple-negative breast cancer six years ago, and it was metastatic to the bone at the time of diagnosis, but with only a solitary lesion in the sternum. This lesion had gotten progressively bigger over time, but her disease had never been found to have spread elsewhere. She had had multiple lines of chemotherapy, the prescription of which had been compromised by her comorbid coronary artery disease. Because her tumor was androgen receptor positive, she had been treated with hormonal therapies on two protocols, but these had had to be discontinued because of intolerable hot flashes. She was now on expectant observation. At the first consultation with me, the patient complained of long-standing pain in the sternum, which had increased in recent months and was excruciating, especially with movement, radiating to both breasts and into the right axilla and upper extremity at times. The latest positron emission tomography scan had again shown the large sternal lesion (5.2 4.6 5.2 cm), which had increased in size compared with the previous scans but with stable [F]fluorodeoxyglucose (FDG) avidity. A softtissue component extended both superficially and deep toward the sternum. There was associated increase in central FDG photopenia in the mass, representing central necrosis. There were no other FDG-avid foci of concern. Her oncologist had tried a fentanyl patch, but even at a dose of only 12 mcg per hour it caused bothersome adverse events (dizziness, dry mouth), so the treatment had been switched to oxycodone, which made her nauseous. Nonopioid analgesics were going to be challenging to use in her case, because of interactions with her cardiac medications and the antidepressants she was taking. Palliative radiation therapy to the sternum had already been given last year to the maximal dosage. Aside from pain and the adverse effects of the pain medicine, she was otherwise without complaint and had an excellent performance status. After a prolonged discussion about the pharmacologic options, she preferred to try fentanyl patches again rather than rotating to morphine or methadone. At the second clinic visit 3 weeks later, she continued to complain of sternal pain with associated numbness. She was tolerating the fentanyl better this time around but had no real improvement in the pain, despite titration of the dose to 37 g per hour. I informed her I would present her case at our monthly Combined Pain Services meeting to inquire about the possibility of intercostal nerve blocks, but I warned her they might not be feasible given that the lesion was so large and invasive. At the conference, my anesthesiology colleague opined that nerve blocks could be offered, but he also raised the option of palliative surgery. So I reached out to our cardiothoracic surgeon who reviewed the imaging and told me she would need a sternectomy, but the procedure could provide good palliation. When I communicated this to my patient, her initial reaction was unexpected. Rather than expressing anxiety, she expressed surprise and consternation, informing me that she had previously asked her oncologist about the possibility of surgery but that her request had been dismissed as an option. The patient called me back a few days later, asking for a referral to the cardiothoracic surgeon. When I informed her primary oncologist of my plan, he told me I was crazy because of her coronary artery disease and the fact that the tumor was abutting the pericardium. Nevertheless, the patient met with the surgeon and chose to have surgery. The procedure went smoothly, clear margins were obtained, and the reconstruction went well. The patient went home after 5 days and, over the next few JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 32 NUMBER 4 FEBRUARY 1 2014