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#ThisIsOurLane: Time for pediatric hematology/oncology providers to join gun violence prevention efforts

Malignant neoplasms are the third leading cause of pediatric deaths in the United States; death by firearms is the second.1 Gun violence affects all communities, but in the United States children die by firearms at a rate 42 times the rate of children in other developed countries.2 This is accounted for, in part, by legislative restrictions prohibiting federal funding by national health organizations, including the Centers for Disease Control and (CDC) and National Institute of Health (NIH), that effectively defunded research on gun violence in two decades.3–5 Pediatric firearm deaths occur most often by suicide in rural areas and most often due to homicide in urban areas, and gun access is the common link.6,7 In the national debate about gun violence prevention, the loudest voices from the medical field often come from those who treat acute gun injuries—trauma surgeons and emergency physicians—and those who see themselves in a prevention role—such as primary care physicians who screen for guns in the home. In 2019, when the NRA advised physicians that issues of gun violence were not within their expertise, many practitioners responded through social media, using the viral #ThisIsOurLane, to express how vital themedical community is to treating and addressing gun violence.8 Subspecialty physiciansmay feel that they do not have a role or a voice in preventing gun-related tragedies. Yet the intersection of social environment and medicine is often amplified for people with chronic and complex diseases. Many subspecialists develop long-term relationships with their patients with chronic disease, and in hematology/oncology, providers often assume the role of a primary care provider.9 Because of this, discussing gun safetywith our patients is within our lane andwemust join the effort to end the gun violence epidemic. A new cancer diagnosis presents intense psychosocial stress on both patients and their families. Pediatric oncologists may feel that there is an endless amount of information to distill with each new diagnosis of cancer; asking about the presence of a gun in the home might not make the list. Studies in adults have demonstrated that patients with cancer are two times more likely to commit suicide than the general population10 there is a paucity of information on pediatric suicide associated with cancer. In our single site experience assessing the efficacy of gun safety teaching among caregivers of hospitalized children and adolescents, we have identified adolescents with feelings of hopelessness as a result of a new oncologic diagnosis and one family had multiple firearms in the home. Risk in this situation does not need to be in the context of clinically diagnosed depression but can be just as lethal in moments of despair combined with adolescent impulsivity and access to a firearm. Of the childhood suicides that do take place, over 60% involve death by a gun1 and studies show that the risk of suicide by firearms is up to 10 times higher in homes with guns than homes without.7 Safe storage was a vital part of discharge teaching for this family and left us to wonder how many missed conversations about gun safety were happening for this high-risk group. The need to continue to shine the spotlight on gun violence prevention persists and has been highlighted during the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic. More than 2.5 million guns were sold in March of this year during the peak of the virus, making it the highest single month gun sale recorded in the United States, up 85% from the previous year. Following this increase in gun sales, there has been an increase in unintentional shootings; the increase in guns purchased coupled with prolonged social distancing and an economic downturn during this pandemic could lead to a suicide epidemic.11 From March to April 2020, there have been 21 deaths by unintentional shooting of children less than 18 years of age, a rise from the average of 15 deaths reported in previous years.12 Moreover, socioeconomic disadvantage has been shown to compound and independently affect psychologic distress and depressive symptoms for caregivers of pediatric cancer patients.13 During the SARS-CoV-2 pandemic, job loss and economic downturn is affecting many families, with greater COVID-19related stressors increasing perceived parental stress.14 The increase in gun access and potential for profound increases in perceived stress and cancer-related stressors during the pandemic could potentiate a higher risk of suicide by firearms; the need for improved safe