CASE

A 34-year-old man with multifocal seminoma testicular cancer diagnosed in 2016 presented to the emergency department (ED) complaining of testicular, back, and abdominal pain. Imaging scans showed a retroperitoneal mass and left testicular mass. Left inguinal orchiectomy was completed, and biopsy confirmed seminoma with final staging as pT1N3M0S1. Due to residual disease, the patient completed 1 cycle of bleomycin/etoposide/cisplatin. Adjustments were made after he developed shortness of breath, and he completed 3 cycles of etoposide/cisplatin.

In 2018, residual disease was removed via retroperitoneal lymph node resection and left colon partial colectomy. One cycle of salvage chemo with paclitaxel/ifosfamide/cisplatin was given but stopped due to acute kidney injury. After recovering, stable tumor markers (beta-hCG) allowed the patient to remain on surveillance.¹

In May 2019, the patient’s tumor markers began to rise, but scans showed no growth of any lesions/masses. The medical team advised more chemotherapy to bring the tumor markers back down to a stable level. However, the patient confided to me that he was interested in exploring alternative/holistic options for keeping the tumor makers down, with the goal of avoiding or delaying more chemotherapy.

As his nurse, I coordinated a meeting between him, his oncologist, a friend, his girlfriend, and his mother, who was out of state and joined via telephone. All participants were given the opportunity to ask questions about the patient’s current cancer status, proposed medical treatment and its side effects, prognosis, and what the current data predict his prognosis would be without the proposed treatment.

The patient discussed possible outcomes with his oncologist. He was encouraged to get a second opinion from an expert in testicular cancer at another facility, which he did. He also had an additional consultation with the radiation oncologist. After multiple discussions with various medical providers, having his questions about treatment options answered, and hearing multiple medical opinions, the patient asked about Rick Simpson Oil (RSO).

RSO, a concentrated cannabis oil, is a version of medical marijuana for which a few case studies have reported improved cancer status and symptoms among users. The patient and I researched several scientific articles and case studies, both pro and con for medical marijuana, to allow for a fully educated decision.²

The patient decided to try RSO instead of any proposed standard treatments, while acknowledging that if his tumor markers started to rise or any tumors developed, he may reconsider undergoing standard treatment/chemotherapy at that time. The patient started this process in July 2019, obtaining the RSO from a local dispensary. The Rick Simpson Protocol advises starting with a rice-grain amount of oil every 4 hours gradually increasing to approximately 1 g per day, then taking 60 g within 90 days.³

The patient has been following this regimen for more than a year. He also has transitioned to an alkaline and plant-based diet and recently started taking higher doses of over-the-counter vitamin C.⁴ He reports having fewer symptoms and feels better than he has in quite a while.

At 1.5 years after initiating this holistic self-guided treatment path, the patient’s disease has remained stable and he reports satisfaction with at least being able to delay chemotherapy for more than a year. He is happy with how he currently feels compared to how he felt while undergoing chemotherapy. Although aware that his future medical status is still unknown, he feels confident that his medical team will be there with him every step of the way.

DISCUSSION

Seminoma testicular cancer accounts for approximately one-third of testicular cancer cases and has a 98% cure rate with standard-of-care chemotherapy regimen.^5,6 After recurrence, the treatment plan typically involves a different chemotherapy and/or stem cell transplant.

Several case studies demonstrate the anticancer effects of Rick Simpson Oil, a version of medical marijuana intended to ease various symptoms such as pain, nausea, and anxiety. Documented risks of this treatment include organ failure, fatigue, and jaundice.^3,7-9 This patient and his medical team addressed these risks with regular laboratory testing so adverse effects could be addressed properly and quickly.

RSO and CBD (cannabidiol) oil are both derived from marijuana (more than 0.3% tetrahydrocannabinol [THC]). RSO uses a recipe of approximately 90% THC, taken from the marijuana flower. It is reportedly most effective when ingested. CBD can be inhaled, vaped, or ingested. The CBD flower is reported to provide relaxing and calming sensations.^3,8,9

Research on the use of medical marijuana is ongoing, and laws regarding its use vary from state to state and are ever changing. Clinicians would benefit from increasing their knowledge of medical marijuana, including the effects of different amounts of THC vs CBD and the pros and cons of each.⁷ Significant data are available showing medical marijuana can act as an appetite stimulant, nausea suppressant, and anxiety reducer^7,8; however, there are also documented arguments stating that marijuana can cause depression and paranoia. Some research studies even point to marijuana use as a possible cause of testicular cancer.^10,11

The topic of medical marijuana is exceedingly complex, which can further contribute to a clinician’s reluctance to consider this as a medical treatment. Nurses play a vital role in patient advocacy and patient education.^12,13 A show of empathy is important for instilling a trusting relationship between the nurse and patient and improving patient outcomes. In this case, if the patient had felt pressured to accept the third line of chemotherapy, he may not have come to follow-up appointments, increasing his risk for adverse effects that often delays treatments and leads to patient discouragement.¹⁴

During the family meeting, the patient and those close to him were able ask questions and understand the information presented. Studies have shown that patients who feel more heard are more apt to open up and provide much-needed information about their concerns and adverse effects.^2,15 In this case, the patient felt comfortable discussing the ins/outs of using medical marijuana with a multidisciplinary team who listened without judgment and came up with a treatment plan that was preferred by the patient and acceptable to the medical team.

TEACHING POINTS

Nurses play an active role in patient education by providing verbal and written information, as well as using techniques such as teach-back to solidify and ensure understanding. This is a key part of nursing that helps patients navigate through treatments and manage side effects.
Nurses play an active role in assisting patient communications with the medical team. Often patients are hesitant to go against provider advice and often forget to ask questions directly to the provider. Nurses can help patients explore and express their wishes by asking open-ended questions and actively listening. This enables a nurse to show empathy as well as understand how the patient is processing the information provided to them.
Nurses play an active role in advocating for the patient by coordinating family meetings and appointment schedules that maximize patient comfort with the team and the treatment plan. By listening to the patient’s and family’s worries and concerns, and providing more time for patient understanding, the patient can feel more confident in making educated decisions.

REFERENCES

1. Gilligan T, Lin DW, Aggarwal R, et al. Testicular cancer, version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Cancer Netw. 2019;17(12):1529-1554. doi:10.6004/jnccn.2019.0058.

2. Glatzer M, Panje CM, Siren C, Cihoric N, Putora PM. Decision making criteria in oncology. Oncology. 2020;98:370-378. doi:10.1159/000492272

3. Risola K. What is Rick Simpson oil? Florida Medical Cannabis Clinic website. June 17, 2019. Updated March 5, 2021. Accessed August 24, 2021. https://www.flmedcannabis.org/news/2019/5/21/tgy7a6qztwx6hiotamvpprdz2ohfpe

4. Mawer R. Can a ketogenic diet help fight cancer? Healthline. Updated January 15, 2021. Accessed August 24, 2021. https://www.healthline.com/nutrition/ketogenic-diet-to-fight-cancer

5. Cedeno JD, Light DE, Leslie SW. Testicular seminoma. StatPearls [Internet]. Last update February 10, 2021. Accessed August 24, 2021. https://www.ncbi.nlm.nih.gov/books/NBK448137/

6. American Cancer Society. Treatment options for testicular cancer, by type and stage. American Cancer Society website. Last revised September 4, 2019. Accessed August 24, 2021. https://www.cancer.org/cancer/testicular-cancer/treating/by-stage.html

7. Lee MA. Marijuana fights cancer and helps manage side effects, researchers find. Daily Beast. Published September 6, 2021. Updated July 13, 2017. Accessed August 24, 2021. https://www.thedailybeast.com/marijuana-fights-cancer-and-helps-manage-side-effects-researchers-find

8. Holland K. CBD vs. THC: What’s the difference? Healthline. Updated July 20, 2020. Accessed August 24, 2021. https://www.healthline.com/health/cbd-vs-thc#further-clarification

9. Jorczyk S. What’s the difference between RSO and CBD oil? CBDOilUsers.com. Published May 8, 2019. Accessed August 24, 2021. https://cbdoilusers.com/difference-between-rso-and-cbd-oil/

10. Cafasso J. Can Rick Simpson Oil Treat Cancer? Healthline. Updated July 12, 2019. Accessed August 24, 2021. https://www.healthline.com/health/rick-simpson-oil-cancer

11. Callaghan RC, Allebeck P, Akre O, McGlynn KA, Sidorchuk A. Cannabis use and incidence of testicular cancer: a 42-year follow-up of Swedish men between 1970 and 2011. Cancer Epidemiol Biomarkers Prev. 2017;26(11):1644-1652. doi:10.1158/1055-9965.EPI-17-0428

12. Davoodvand S, Abbaszadeh A, Ahmadi F. Patient advocacy from the clinical nurses’ viewpoint: a qualitative study. J Med Ethics Hist Med. 2016;9:5.

13. Abbasinia M, Ahmadi F, Kazemnejad A. Patient advocacy in nursing: a concept analysis. Nurs Ethics. 2020;27(1):141-151. doi:10.1177/0969733019832950

14. Hart RI, Cameron DA, Cowie FJ, et al. The challenges of making informed decisions about treatment and trial participation following a cancer diagnosis: a qualitative study involving adolescents and young adults with cancer and their caregivers. BMC Health Serv Res. 2020;20(1):25. doi:10.1186/s12913-019-4851-1

15. Grant SM, Johnson BH. Advancing the practice of patient- and family-centered care: the central role of nursing leadership. Nurs Lead. 2019;17(4):325-330. doi:10.1016/j.mnl.2019.05.009