Making CANCER TREATMENT DECISIONS during Covid-19: an Example from Mythology – Scylla and Charybdis

In Greek mythology, Scylla and Charybdis are two sea monsters living on opposite sides of a narrow channel. The two shores of the passage are within bowshot of each other, so close that sailors trying to avoid Charybdis find themselves approaching Scylla, while those trying to avoid Scylla approach Charybdis. From this comes the expression being caught between Scylla and Charybdis which has been used for situations in which a person faces two dangers and moving away from one brings them closer to the other.

Today, Scylla and Charybdis can be expressed through the sayings "being caught between two fires" or "spit down and you hit your beard, spit up and you hit your mustache".

Below, in a perspective article published in NEJM, a leading medical journal, you will read excerpts from the words of an oncologist caught between Scylla and Charybdis:

‘’Doctor, should we activate the sepsis protocol (the steps to take in a serious, life-threatening infection)?’’ My resident had asked this anxiously. I had carried out the patient's initial assessment. Her striking symptoms on arrival were palpitations and rapid breathing. However, this middle-aged woman had neither a fever nor low blood pressure. During the examination, she was indeed breathing rapidly and had a fast, regular pulse. Yet there were major clues to the cause of the problem. Her pupils were dilated. She was sweating and tapping her feet against the floor. After some questioning, all the evidence pointed to a hyperadrenergic response to extreme anxiety.

Facing a New and Different Fear

I am a medical oncologist. With disturbing frequency, I tell people they have cancer, and in many cases I also have to add that their disease cannot be completely cured. A ringing in the ears often accompanies these conversations – at the moment patients are diagnosed with cancer, this is all they hear, and they can hear nothing more afterward. I have witnessed many fears throughout my career, but I have never seen anything like the panic my patients have experienced with the emergence of the novel coronavirus (SARS-CoV-2).

Weighing Benefits and Harms

As oncologists, we are used to putting danger into perspective with percentages. Through difficult calculations, I try to show my patients that the benefits of chemotherapy will outweigh its side effects. When administering cytotoxic (cell-killing) drugs, I carry percentages around in my head. Patients' choices, however, often come more from their amygdala, the brain's fear center, than from other parts of their brains. To continue their demanding treatments, patients' fear of death must outweigh their fear of the drugs that will be put into their bodies.

Each Patient's Internal Reckoning Is Different

Even the slightest chance of improvement can persuade patients to accept a drug. I am quite surprised by the willingness of patients to receive certain drugs with substantial harmful effects because they believe they will derive an "exceptional benefit." But that was until now.

As deaths increase because of the Covid-19 Pandemic that the world is struggling with, my patients have become focused only on the deaths. Despite the evidence I show them, they no longer want chemotherapy. Chemotherapy regimens, which were never particularly welcome, are now even more frightening to them.

Although This Outbreak Poses a Global Threat, Some Groups Appear Particularly Vulnerable to Illness and Death

Chinese researchers reported that patients with cancer affected by Covid-19 have a higher risk of admission to intensive care and death. The prolonged immune deficiency caused by cancer, and probably advanced age, account for this. Despite the unsettling factors, most patients with cancer, particularly while receiving treatment, perceive their existing disease as a greater risk than Covid-19.

My troubled conscience now wrestles with the increasingly complex calculations of probability facing patients with cancer: is it better for my patient, whose immunity has been reduced by treatment, to come closer to succumbing to Covid-19, or to pay the price of delayed or entirely canceled treatment? Avoiding SARS-CoV-2 only for the patient's cancer to progress later because they have not received treatment would be like moving forward with heavy losses. The inevitability of infection and the chronic nature of cancer bring oncologists and patients face to face with Scylla and Charybdis, between whom they must chart a truly cautious course. This is precisely where one is caught between two fires.

Only time will tell what the picture will look like as we encounter Covid-19.

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