Making Healthy Choices for Life

After actor Patrick Swayze died of advanced pancreatic cancer, his treating oncologist appeared on Larry King Live and was asked about Swayze’s decision to continue smoking after his diagnosis. “I think at the point that one is already diagnosed with cancer, there’s little additional harm in it. And if it seems to provide him some comfort or partly identity of who he is, I certainly have no objections to that,” he said.

The comment elicited debate among oncologists and antismoking advocates, who pointed to studies showing that patients who stop smoking immediately after a cancer diagnosis typically have better outcomes. Now, the prognosis for patients with advanced pancreatic cancer is grim, as we all know. The median survival is 5 months, which Swayze beat by about 15 months. Would he have survived longer had he quit smoking? That is something we will never know.

The situation invites an interesting question, however. Do oncologists have a responsibility to encourage patients with cancer to make healthy lifestyle choices? The Centers for Medicare & Medicaid Services seems to think so. They have established CPT codes to allow oncologists to seek reimbursement for counseling patients on smoking cessation, and the Physician Quality Reporting Initiative (PQRI) includes two measures relating to inquiries on tobacco use or smoking cessation counseling.

The advances in cancer therapies and the growing number of people who get screened regularly for various cancers has led to better rates of overall survival in many solid tumors and hematological malignancies. To illustrate, an M. D. Anderson study published in the May 26 Journal of Clinical Oncology said in the early to mid-1990s, most patients who received a colorectal cancer diagnosis survived a median of 14 months. Now, survival after diagnosis averages 30 months, and 5-year survival rates have increased from <10% to approximately 30%. Women with breast cancer, in particular, are enjoying vastly improved survival outcomes. As a result, a recent study at the Breast Cancer Symposium said 43% of women treated with aromatase inhibitors for early stage breast cancer were as likely to have a serious cardiovascular event as breast cancer recurrence in the next 10 years.

We know obesity increases the risk of cancer. According to some studies, it also decreases long-term survival in patients who already have cancer. Exercise has been associated with better outcomes in various cancer types, and patients under stress have poorer outcomes.

Lifestyle changes such as quitting smoking, eating healthy, staying fit, decreasing stress, avoiding alcohol abuse, and getting ample rest are advisable for everyone, cancer or no cancer. Considering everything patients with cancer go through in an effort to live longer and all the resources invested, sudden death from what might be a preventable heart attack seems all the more tragic. Even when giving a prognosis that does not leave much hope, there’s no harm in encouraging our patients to prepare for the best and work toward adopting a healthier lifestyle.

Obviously, we do not want to add to any stress patients might be feeling or induce guilt that they are not doing enough for themselves, and this leaves oncologists with a tightrope to walk. The best approach is to offer encouragement instead of condemnation and reassure patients that we understand how difficult it can be to make these lifestyle changes. We might encourage overweight patients to exercise, for example, by talking about how it is a great stress reliever and can help strengthen bones; or mention how some anticancer therapies affect the heart, so it helps to reduce other sources of cardiac stress, like smoking. We can also refer them to the appropriate professionals, such as nutritionists or psychologists. Patients need to know we are not being judgmental; we just want the same thing for them we want for all patients: to see them live as long as possible and enjoy superior quality of life for their remaining days.