Is It Physician or Individual or Both: Whose Preference Matters Finally?

Sir,

This is about a 63-year-old gentleman, known diabetic and hypertensive, having good performance status (PS) (Eastern Cooperative Oncology Group-1 [ECOG 1]), who presented to the outpatient clinic with the complaint of an ulcerative lesion on bilateral buccal mucosa for the past 3 months. The lesions on each side of the buccal mucosa started around the same time and now gradually increased in size and were associated with pain/irritation on chewing with reduced mouth opening. He denied any history of dental trauma/procedure. Moreover, he had a habit of moderate alcohol use and was a tobacco chewer (stopped just 2 months back) and a current smoker (pack-year 67.5; 30 cigarettes daily) for the past 45 years. Despite all these, he enjoys his life enthusiastically with family and friends.

On examination, he had moderate (Grade II) trismus with an ulceroproliferative growth on the bilateral buccal mucosa, extending from the first molar to the retromolar trigone region with the involvement of the superior gingiva-buccal sulcus on the right side, while on the left side, it extends from the second molar to the retromolar trigone along with one submandibular (2 cm × 1 cm) and one upper deep cervical palpable lymph node (2 cm × 2 cm).

An individual incisional biopsy of buccal mucosa lesions revealed well-differentiated squamous cell carcinoma. Contrast-enhanced computed tomography (CECT) of the face and neck showed soft-tissue lesion in the right buccal mucosa and upper alveolus with infiltration of the right medial and lateral pterygoid muscles and subtle erosion of medial and lateral pterygoid plates along with soft-tissue lesion on the left buccal mucosa and enlarged lymph nodes in the right submandibular and upper cervical region. As a part of the staging workup, CECT thorax was done, which showed no abnormality, and so, staging as per the AJCC 8^th manual was cT4bN2bM0-composite Stage IVB.

On evaluation by the multidisciplinary team, the patient was considered for chemoradiotherapy due to unresectable lesions, given the erosion of pterygoid plates but with ECOG 1. The patient and his attendant (son) were counseled regarding the prognosis, treatment details, and reported possible outcomes. After further discussion and considering the patient’s unwillingness to hospitalize or a long (2 months) continuous treatment with chemoradiotherapy, we all together decided to start only a metronomic chemotherapy in the form of an injection methotrexate 50 mg/week and continue it until progression/poor tolerability as it is also an evidence based for this stage of carcinoma buccal mucosa in patients with poor PS or less support or poor logistics as a palliative measure. The patient has till now completed 65 weekly cycles of injection methotrexate with good tolerability and has a near-to-complete clinical response without radiological or pathological confirmation.

He was also asked and assessed for his willingness to quit smoking. However, despite the danger of advanced oral cancer that has already manifested and the short life span ahead of a few months to years, he is not willing to quit and not even ready to accept assistance with smoking cessation medication as it provides him pleasure. Moreover, he says that why stop when this will not cure the disease, not even change the trajectory of the disease, and maybe I will not be alive to reap the long-term benefits of quitting?

However, being a palliative physician as well as an oncologist, we know that my role is always to support the patient’s autonomy as much as possible and, at the same time, need to keep patients’ health in mind and accept treatment denial only when the outcomes are likely to be too poor in comparison to the justification of treatment (nonmaleficence and beneficence). The background of these ethical principles (autonomy, nonmaleficence, and beneficence) actually raises many questions in my mind such as (1) whether we should allow him to continue smoking as an older adult with advanced cancer and a smoking habit for decades or convince him repeatedly to quit before starting any cancer-directed therapy, which may not be easy for sure; (2) What is the impact on his day-to-day life if he opts to quit? (3) Does it affect the outcome in a patient with a short life span ahead? and (4) Should we stop/not start all the treatment if he opts not to quit? With this question in mind, we search for them in medical literature for guidance.

As we know, tobacco addiction is a medical problem that deserves medical treatment. Hence, individuals, once they start smoking, may lose their autonomy due to its addictive potential. Evidence showed that smoking could increase mortality irrespective of cancer stage with early as well as advanced or metastatic cancer.[1] Many studies demonstrated increased treatment failure and treatment-related toxicity and reduced efficacy of systemic treatments such as chemotherapy and immunotherapy with continued smoking.[2,3,4,5,6] Along with avoiding complications, smoking cessation after a cancer diagnosis can reduce the risk of second primary cancer, improve cancer-related survival, and improve treatment outcomes with better quality of life.[4,6,7] Studies have also shown that patients who continue to smoke have persistent pain with increased severity, increased analgesics requirement, and decreased day-to-day activities in patients with advanced cancer compared to former smokers, which improves with the increasing duration of smoking cessation.[8,9,10,11] Moreover, this can also result in improved respiratory symptoms such as breathlessness and cough and increased control over his life. Besides personal gain, it will reduce the negative impact of smoke exposure on other family members and increase their happiness index.

Hence, health-care professionals, irrespective of palliative care philosophy, should use cancer diagnosis as the “teachable moment” to introduce cessation support for maximizing the remaining quality of life.[11,12,13] However, patients with poor prognoses of cancer are less motivated than favorable ones (like this gentleman).[13] According to surveys about smoking cessation efforts, about 80%–90% of oncologists regularly ask and advise patients to quit smoking, and only 30%–40% assist with counseling or medications.[14,15,16] However, patients with advanced cancer on treatment strategy with palliative intent received lower support, with only 54% of oncologists advised to quit and 18%–24% provided counseling or medications.[14,15,16] This finding shows the contradiction that the patients requiring more counseling or efforts are getting fewer tobacco cessation efforts. Even the oncologists undervalue tobacco cessation and view this as a lost opportunity in the palliative setting, mainly due to the reported hesitations of uncomfortable feelings.[14,15,16] Instead, an effective smoking cessation strategy for patients with cancer, even at an advanced stage, should be the fourth pillar as an integral and essential component for the comprehensive management of cancer.[14]

Palliative care seeks to improve the quality of life not only by addressing the physical symptoms but also simultaneously addressing the psychosocial and spiritual aspects of the life of a person diagnosed with a life-threatening illness. Following the basic concepts of palliative, such as being individual-focused, expressing empathy, evoking patient motivation, increasing mutual discussion, expressing acceptance and compassion, and encouraging the patient’s urge to quit, we can make these patients who are not willing to quit to decrease their smoking as a part of harm reduction strategy (like we followed in our patient). Asking patients their thoughts about becoming free from tobacco and offering supportive treatment can improve their multiple personal and social outcomes; thus, it should be considered an essential intervention for palliative care.

Ethically, we should not refuse medical treatment even if the patient is willing to forgo their tobacco use. Therefore, even if a physician concludes that cancer-directed therapy or any other intervention will not benefit the patient, they are still responsible for advising the patient to seek alternative treatments, including palliative approaches to care.

With persistent and compassionate efforts, this gentleman reduced smoking from 30 to 2–3 cigarettes daily (he confessed himself on the last follow-up). In addition, he has an excellent clinical response to metronomic chemotherapy without being hospitalized. And not only that, but also this time, he shared his joyously enjoying independent journey to Rishikesh and other pilgrimages without even seeking family support. And so, we also want to share and extend this joy and satisfaction to our community.

CONCLUSION

This case reflects the full-filled journey of a 63-year-old gentleman and mine as a palliative physician cum oncologist who jointly achieves the goal of harm reduction and meaningful clinical response to disease while maintaining the quality of life of his own choice, well within the boundary of ethical principles (autonomy, nonmaleficence, and beneficence).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.