Find Your Champion: Treating Patients Diagnosed With Cancer and Substance Use Disorder

Patients with comorbid cancer and substance use disorder (SUD) diagnoses face unique challenges. Historically, oncology training has not fully prepared clinicians to care for patients struggling with addiction.

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Recent research and developments have helped improve these trainings over time. But there remain many untapped opportunities for clinicians to strengthen their treatment approaches to patients with these two diagnoses.

Helen Shih, MD, is the medical director of the Proton Therapy Centers at the Mass General Cancer Center. In her career, Dr. Shih has pursued solutions to the addiction crisis and sought to better understand the struggles of patients diagnosed with cancer and SUD. Her work on the Substance Use Disorder Tumor Board in the Mass General Cancer Center brought together a multidisciplinary team of clinicians who came together to treat and guide these patients. This effectively forged a path forward for optimizing treatment outcomes.

In this piece, Dr. Shih shares her learnings and offers advice about treating patients in this difficult circumstance.

Q: What was the Substance Use Disorder Tumor Board?

Shih: The Substance Use Disorder Tumor Board came together in the Mass General Cancer Center. We sought to find the best care for people who have both SUD and cancer, with possible needs for surgery, chemotherapy and other medication treatments, and/or radiation therapy. Pain is often part of the disease or a result of part of treatment. Opioids are frequently used to manage severe pain and can lead to patients becoming addicted to them.

The Substance Use Disorder Tumor Board was more than physicians. Mostly, it was led by nursing—the front-line providers who really work day-to-day with patients. These were most often advanced practice providers of physician assistants and nurse practitioners representing their teams, bringing forth cases and saying, "We have this individual. They have cancer and need this specific treatment. They're not coming in," or "They're coming in and they're demanding drugs," or "They're coming in drunk and belligerent. How do we help them?" We didn't have a system to address these problems at the time. The helpers were other members of the Cancer Center with an interest in these patients, including social services, psycho-oncology psychiatry, and cancer physicians. We also recruited the assistance of pain medicine specialists, addiction psychologists, and addiction medicine specialists.

We found three categories of patients:

1. People who were actively using and misusing drugs, essentially with but not always with a formal SUD diagnosis yet —They were unable to control drug use and needed someone who could look beyond that and realize there was a hurting person inside.
2. People at risk of developing SUDs—They start experiencing the "high" or euphoria when taking opioids and are tempted to continue to use, with varying degrees of awareness. Some people are just slightly more prone to addiction, and easy or abundant access to these medications tempts their use.
3. People in recovery, struggling through each day, but then got cancer—These people have the greatest awareness of the struggle of addiction and fear relapse. I've worked with patients like this saying that after surgery, they were in so much pain, but they were too scared to take pain medication because they didn't want to risk relapse. Other people did just relapse.

So, there are multiple facets of challenges, and we're still trying to figure out how best to address this.

I think the most useful thing the Substance Use Disorder Tumor Board did first was raise awareness that this is a real issue. Second, it made us create an infrastructure for management.

Q: What has been the impact of the Substance Use Disorder Tumor Board on treating patients with cancer and SUDs?

Shih: The Substance Use Disorder Tumor Board disbanded with COVID-19, and it hasn't needed to come back together because we've created a pathway.

One thing we now know is that the Social Service Department is imperative. They become the point people. This wasn't recognized before—the pathways didn't exist for them to come in and triage an individual. But they're the people who can make a first meaningful connection and reach out such as offering, "I can counsel you. This is a first step and may be all you need versus medical therapy that may otherwise be indicated."

Beyond that, they're also well connected with the Substance Use Disorders Initiative at Mass General. They might be pulling in people from addiction medicine or psychology for support. This may also include the Department of Psychiatry, which is a division in the Cancer Center with Psycho-Oncology that has been very involved with these patients, and also the Pain Medicine group, which is best at advising which pain medications to use and how best to use them to achieve cancer pain control with minimizing risks of worsening SUD. Most of us are now aware of the breadth of resources at Mass General, of each other, and together we look to provide the best-integrated care for patients. The village needed to care for these complex patients was not well recognized or created formally 10 years ago, and so we are in a far better spot today overall. Each case is still challenging when it arises, and occasionally I am approached for help.

Q: How can a multidisciplinary care team support patients diagnosed with cancer and SUDs?

Shih: In some multidisciplinary groups, there's a champion—a clinician team member with a personal interest—who acts as a point person. Usually, help ends up involving social services. A physician or advanced practice provider will ask, "We have a patient with these two diagnoses. Who can step in first?" It is now usually the social worker with the champion's support. Sometimes patients need a higher level of care and working together, social services and the champion clinician will then make the appropriate referrals.

Q: How can medical oncologists and surgical oncologists be supportive of patients who have been diagnosed with both cancer and SUDs?

Shih: First is just being educated. If you're aware, then you can identify patients struggling with SUD. It's about supporting them, acknowledging them, being clear that we respect and are committed to helping them, and getting additional support. If we ignore it, we're ignoring part of a person's identity of who they are.

Don't be judgmental. Just show support. Say, "Look, I know the past has been a challenge but I believe in you. The journey ahead is hard, but you can do it. We're going to do it together."

I once asked a former patient what was most meaningful in his recovery. He named one of the many nurses who cared for him, someone who kindly took care of him in an emergency department during a near fatal overdose. You never know when you'll be the person playing that part that helps to make that click of commitment to recovery so we always have to try. Maybe most of us will be forgotten by any one person. But I think just being there as a positive force is amazing.

Q: Are there any specific resources related to this topic that you'd like to highlight?

Shih: Yes. Right now, there is a branch of Mass General Psychology specifically interested in providing additional care for cancer patients who have active SUDs—alcohol or other substances—and providing 12 complimentary weeks of weekly therapy sessions. This is a wonderful parallel effort to the rest of cancer care that aims to get affected patients into a good space. If you have a patient with an active SUD who might benefit from this, you can email us for screening for appropriateness for outpatient therapy.

Learn more about the Substance Use Disorders Initiative at Mass General

Learn more about the Mass General Cancer Center