Survivors of cancer despite poor quality of care are heroes.

Abstract

Bigelow et al must be commended for investigating the burden of comorbidities among survivors of oropharyngeal cancer.1 Their results may be not be surprising, but they certainly highlight that there is much room for improvement. First, databases bear witness of a global issue. In Table 1 in the study by Bigelow et al,1 the cancer stage was available for approximately 14% of patients. The category titled “alcohol abuse” overlooked that alcohol becomes a dose-related human carcinogen beginning at 1 to 2 drinks per day. The threshold of the National Institute on Alcohol Abuse and Alcoholism for low-risk regular drinking for healthy people who choose to drink is 14 drinks per week for men (196 g of pure alcohol; in the United States, a typical drink contains 14 g) and approximately one-half that for women. However, a standard glass of wine (175 mL/6 fl oz, 13% alcohol by volume) contains 18 g of pure alcohol and self-reporting appears to underestimate its use. In Europe, the threshold is 100 g per week for men and women. Last, alcohol is an addictive substance. Augustine of Hippo advised “complete abstinence is easier than perfect moderation.” Finally, in the study by Bigelow et al, data regarding the most important item for the patient, quality of life, was not available, but information regarding hyperlipidemia was. Increasing quantity (Surveillance, Epidemiology, and End Results data cover approximately 35% of the population) is a rush forward toward precluding quality: garbage in, garbage out. Simple random sampling allows for resources to be devoted to better quality: small is beautiful. Second, at the time of diagnosis, approximately 13.2% of patients were smokers, as shown in Table 2 of the study by Bigelow et al,1 and the cumulative prevalence remained >10% for survivors, as shown in Figure 4.1 This is a shipwreck. Ramaswamy et al warned that only approximately one-half of patients with cancer who smoke are counseled to quit, although cessation is most important for outcomes (treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life).2 Furthermore, when counseling is provided, it is nearly a programmed failure.3 The “5As” guideline, which begins with “Advising users to quit,” followed by “Assessing willingness to quit,” also is almost a programmed failure. Tobacco is among the most addictive products; all smokers have made serial cessation attempts, and fail with suffering and despair. No one expects to be able to quit. The “5As” points the finger of blame at a victim who never received adequate assistance from the system: CNN dared to call a spade a spade in a recent report.4 The cornerstone for cessation is reassurance by specialists for: 1) motivational interviewing and psychological support, which means time and skill; and 2) monitoring the “belt-and-braces” strategy combining nicotine patches with oral “rescue” formulations (ie, sprays and lozenges) to suppress occasional cravings. Doses must be increased without fear until no craving remains but too many people and professionals are more scared of nicotine than of carbon monoxide or tar, and overlook the devastating effects of compensatory uptake when trying to reduce smoking without the use of nicotine patches.5 Never require quitting, allow smoking but require patients to increase doses as needed, until the craving, which is just pain, vanishes. Never set a quit date as recommended; smokers will naturally quit when no cravings remain and cigarettes are viewed as distasteful. Do pain physicians establish a date for their patients to be pain free? Last, do not allow the use of e-cigarettes. Vaping is not quitting and must be included among International Agency for Research on Cancer group 2A carcinogens (“limited evidence of carcinogenicity in humans and sufficient evidence of carcinogenicity in experimental animals”): the development of lung adenocarcinomas and bladder urothelial hyperplasia has been documented in mice, confirming in vitro experiments in various species.6 Michelangelo's warning that “The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark” must be our motto. No specific funding was disclosed. The author made no disclosures.