Smoking cessation should be ‘pillar’ of the cancer treatment protocol
Tobacco use is the leading preventable cause of cancer, responsible for nearly 30% of cancer-related deaths in the U.S. annually.
Studies have shown that many patients continue to smoke even after receiving a cancer diagnosis. Although some patients may feel as if the damage is done and quitting after diagnosis is futile, smoking cessation should remain a priority, as tobacco use has been linked to poorer cancer outcomes and risk for secondary cancers.
In fact, according to a commentary published in JAMA Network Open, some experts now consider smoking cessation the fourth pillar of cancer care after surgery, radiotherapy and chemotherapy.
More attention has been given to the role oncologists should play in discussing tobacco use and actively encouraging smoking cessation among their patients. However, not all oncologists have the bandwidth or the resources to promote tobacco cessation.
“It is imperative to encourage smoking cessation [among] patients with cancer. However, there are barriers in getting oncologists and other health care providers to talk about smoking cessation with their patients,” J. Lee Westmaas, PhD, scientific director in the Behavioral and Epidemiology Research Group at American Cancer Society, said during an interview with HemOnc Today. “There is a belief that patients do not want to quit — or if they are going through a cancer diagnosis, adding another burden by asking them to quit smoking is not a good idea. But, given the importance of quitting smoking and what it means for treatment, it is imperative that patients with cancer stop smoking and that we help them do so.”
HemOnc Today spoke with experts about the latest research regarding the impact of smoking on cancer treatment and survivorship, oncologists’ role in smoking cessation, barriers to providing smoking cessation for patients with cancer, and the availability and effectiveness of tobacco-dependence treatment programs for these patients.
Smoking prevalence, impact
Patients with cancer and survivors who smoke have poorer cancer outcomes, worse response to treatment and lower survival rates than patients who stop smoking after their cancer diagnosis, Alex T. Ramsey, PhD, assistant professor of psychiatry at Washington University School of Medicine, told HemOnc Today.
“Smoking is an effect modifier of cancer treatment and one that hurts cancer prognosis for cancer outcomes moving forward,” Ramsey said. “It is extremely important to encourage smoking cessation among patients with cancer, because quitting smoking after a cancer diagnosis improves outcomes and response to treatment and lowers the risk for developing a second cancer.”
A study by Tabuchi and colleagues that included nearly 30,000 patients with a first cancer from a population-based cancer registry in Japan showed ever-smokers had a 59% greater risk for all second primary cancers and a 102% higher risk for all smoking-related second primary cancers than never-smokers.
Compared with those who had never smoked, cancer survivors who had ever smoked had a significantly higher risk for oral/pharyngeal, esophageal, stomach, lung and hematologic second primary cancers, regardless of their first cancer site.
Of note, cancer survivors who had recently stopped smoking had an 18% to 26% lower risk for second primary cancers than those who smoked at diagnosis.
Smoking following a cancer diagnosis also can make treatment less effective.
Alfayez and colleagues investigated the impact of smoking on relapse risk and treatment outcomes among 561 newly diagnosed patients with acute myeloid leukemia.
Results, presented at last year’s ASCO Annual Meeting, showed significant associations between smoking and lower odds of achieving clinical response to treatment (OR = 0.6; 95% CI, 0.41-0.88) and higher odds of having a complex karyotype (OR = 2.14; 95% CI, 1.44-3.22). In addition, a greater proportion of ever-smokers relapsed than never-smokers (43% vs. 30%; P = .0091).
“Smoking impacts cancer treatment itself,” Frank T. Leone, MD, MS, professor of medicine in the division of pulmonary, allergy and critical care at University of Pennsylvania Medical Center, told HemOnc Today. “Tobacco use undermines the ability of many cancer therapies to get their job done. Smoking significantly impacts wound healing and there is increased risk for complications, such as heart disease and stroke — there is a higher probability for all of this.”
Still, nearly 64% of cancer survivors continued to smoke after cancer diagnosis, according to an analysis by Tseng and colleagues of data from the 1999 to 2008 National Health and Nutrition Examination Surveys.
Among the 566 cancer survivors aged 20 years and older included in the analysis, more than half reported smoking regularly prior to a cancer diagnosis, and only 36.1% stopped smoking after diagnosis. Researchers noted that cessation rates appeared similar among those with smoking-related and nonsmoking-related cancers.
Further, a study by Westmaas and colleagues that followed 2,938 10-year survivors showed that even 9 years after a cancer diagnosis, 9.3% of the survivors smoked. Eighty-three percent of these survivors smoked daily, smoking nearly 15 cigarettes a day.
Smoking cessation as ‘component of cancer care’
Experts with whom HemOnc Today spoke unanimously agreed that the oncologist and the entire cancer care team play an important role in connecting patients with cancer who smoke to evidence-based smoking cessation programs and treatment.
“Oncologists should demand that legitimate resources are available to help their patients stop smoking,” Leone said. “They are in a position to identify smoking status, refer patients to treatment facilities and prescribe treatment on the first visit with the patient. Oncologists should think about smoking cessation as a component of cancer care.”
This also applies to the patient with end-stage cancer, despite having limited time left.
“Quitting smoking improves quality of life for everyone, including patients with end-stage cancer,” Li-Shiun Chen, MD, ScD, MPH, associate professor of psychiatry at Washington University School of Medicine, told HemOnc Today. “If a patient needs nicotine, they should use a safe source like the nicotine patch instead of cigarettes so breathing can be much easier.”
Many societies — including ASCO, American Association for Cancer Research and International Association for the Study of Lung Cancer (IASLC), among others — have issued policy statements on the oncologist’s role in promoting tobacco cessation among patients with cancer.
In ASCO’s policy statement — published in Journal of Clinical Oncology — Hanna and colleagues wrote that “physician-relayed advice on smoking cessation increases the likelihood that patients will try to quit and enhances the odds that those who do so will remain tobacco-free. Even brief tobacco-dependence treatment interventions are effective and should be offered to all tobacco users.”
The statement also cited long-term smoking cessation rates of 15% with counseling, 22% with medication alone, and 22% to 28% with a combination of counseling and pharmacotherapy.
Ultimately, Hanna and colleagues described tobacco cessation as “a core prevention and treatment activity for all oncology providers.” They wrote that oncologists “must remain vigilant about tobacco use and its unfortunately high relapse rates” due to the negative impacts of tobacco during cancer treatment and survivorship.
“Patients respond best when all members of the oncology team provide a consistent message that quitting smoking is one of the best things that patients can do to fight their cancer,” Ramsey said. “Oncologists should do this regardless of the patient’s interest in stopping smoking because interest and motivation in stopping smoking fluctuates over time. It is important to give that consistent message and encouragement to keep trying to quit and to continue providing resources to facilitate quit attempts.”
In an IASLC declaration — issued last year during World Conference on Lung Cancer — the society recommended all physicians screen their patients with cancer for tobacco use and recommend tobacco cessation.
The declaration described cancer diagnosis as a “teachable moment” wherein oncologists can engage in shared decision-making with their patients about quitting smoking, at a time when patients may be more likely to quit with assistance.
“A diagnosis primes or motivates many people to want to make changes to their lifestyle or health habits to improve their chances of beating the cancer,” Westmaas said. “This can include eating healthier and/or quitting smoking.”
For instance, results of a large observational prospective cohort study by Westmaas and colleagues showed a significantly greater proportion of subsequent quitting among those who had received a cancer diagnosis compared with those who didn’t in the same time period (2-year quit rate, 31.3% vs. 19.5%), even for cancers less strongly linked to smoking.
“Despite wanting to take steps to quit, some patients may be reluctant to bring up their own smoking status because they may feel ashamed, embarrassed or guilty that they caused their cancer,” Westmaas added. “These feelings, including anxiety or depression, may lead to continued smoking in an attempt to cope. They also may feel stigmatized about being a patient with cancer who smokes. This is why it behooves providers to address this either by bringing it up themselves or through their institution.”
Despite such policy statements, data from the surgeon general’s report on smoking cessation issued earlier this year indicated that 40% of smokers are not advised by health providers to stop smoking, even though 70% want to quit.
According to the AACR policy statement, a lack of resources may be partially to blame.
The society’s report includes survey data showing that 61% of oncologists provided smoking cessation services, but only one-third of them had general training in cancer prevention.
Moreover, studies have shown that less than 10% of providers had training specifically in smoking cessation.
Warren and colleagues conducted an online survey of 1,507 IASLC physician members to assess practices, perceptions and barriers to tobacco assessment and cessation for patients with cancer.
According to the findings, published in Journal of Thoracic Oncology, more than 90% of physicians acknowledged that current smoking status affects cancer outcome and, thus, smoking cessation should be a standard part of clinical care.
Although 90% of physicians reported inquiring about tobacco use during the initial patient visit, only 40% reported discussing medication options with their patients, 39% reported actively providing cessation assistance and even fewer reported addressing tobacco use at follow-up visits.
“Cancer-specific barriers cause the lack of these discussions in the enormity of initial patient visits,” Leone said. “Patients are so overwhelmed by the diagnosis. When the world at your feet is on fire, it is difficult to have a broad perspective on all the things that can be done to help with outcomes. This is true for both the patient and the oncologist.”
Most physicians who responded to the survey by Warren and colleagues reported pessimism regarding their ability to help patients stop using tobacco (58%) and concerns about patient resistance to treatment (67%) as barriers to smoking cessation interventions.
Moreover, only 33% of physician respondents reported that they were adequately trained to provide such interventions.
In another survey of tobacco-use treatment services at 58 NCI-designated cancer centers, Goldstein and colleagues found 20.7% of NCI-designated cancer centers reported no smoking cessation services. Only 62% reported routinely providing tobacco education materials to patients.
Additionally, just over half reported effective identification of patient tobacco use and less than half reported having an employee devoted to providing smoking cessation services or a clear commitment to providing these services from cancer center leadership.
“For most cancer centers, the biggest barrier is knowing how to connect patients to smoking cessation programs. Some NCI-designated cancer centers have received funding to focus on how to make this connection easier,” Cho Y. Lam, PhD, research associate professor in the department of population health sciences at Huntsman Cancer Institute and University of Utah, told HemOnc Today.
Beyond institution-level barriers, cessation can be hard on patients.
“Radiotherapy and chemotherapy leave patients feeling tired and it is difficult for patients to attend smoking cessation programs in person, which is why we provide sessions over the phone,” Lam said. “We also aim to arrange in-person visits on the days that patients are already coming to the cancer center for treatment or follow-up. We do all of this so that the patient is more likely to stay on the smoking cessation program.”
‘Arsenal of smoking cessation tools’
Developing readily available evidence-based interventions has become a priority as institutional barriers have become publicized.
Moreover, data show that center-based smoking cessation programs work.
In a study published in 2019 in JAMA Network Open, Cinciripini and colleagues found that comprehensive tobacco-dependence treatment appeared to help patients with cancer successfully abstain from smoking.
Of the 3,245 smokers included in The University of Texas MD Anderson Cancer Center’s tobacco treatment program, researchers observed mean smoking abstinence rates of 45.1% at 3 months, 45.8% at 6 months and 43.7% at 9 months. Patients with head and neck cancer had the highest smoking abstinence rates.
This could demonstrate to other cancer centers that such programs are worth the investment, Lam said.
“MD Anderson Cancer Center has provided smoking cessation programs for more than a decade,” Lam said. “Cinciripini and colleagues have now shown us impressive and phenomenal smoking abstinence rates with these programs, which is very encouraging.”
A key component of the NCI’s Cancer Moonshot is funding provided to NCI-designated cancer centers for the development of population-based approaches to connect all patients who smoke with tobacco treatment services.
As part of this, researchers developed the Cancer Center Cessation Initiative (C3I), which provides an opportunity to identify effective implementation strategies and barriers to delivering tobacco treatment services across multiple clinical oncology settings.
In a study published last year in Cancer Prevention Research, D’Angelo and colleagues reported data from 22 cancer centers after receiving 18 months of NCI funding for this initiative. Data showed progress in hiring tobacco treatment specialists, adding novel tobacco treatment programs and integrating electronic health record-based tobacco treatment referrals.
Researchers observed an increase in the number of C3I-funded centers that offer in-person smoking cessation counseling, from 10 (45.5%) to 18 (81.8%). In addition, they observed an increase from 27.3% to 50% in optional EHR-based referrals to tobacco treatment programs and from 4.5% to 40.9% in automatic EHR-based referrals.
Compared with 4.5% of centers prior to funding, 27.3% offered text-based cessation programs and 22.7% offered web-based cessation programs.
The average reach rate for C3I programs was about 25%, which researchers said compared favorably with the 15% or lower rate observed in primary care settings.
Use of the EHR can provide a built-in check to ensure providers ask patients about their tobacco use during visits. However, changes to the EHR “affect not only the cancer center clinical workflows, but often are made throughout an entire health care system and require significant financial and organizational leadership,” D’Angelo and colleagues wrote, noting that only one NCI-designated cancer center in their analysis had an automatic EHR referral program at baseline.
But, successful implementation of such changes can reap dividends.
Huntsman Cancer Institute uses the Ask, Advise and Connect strategy, which is integrated into the center’s EHR system, to ensure all patients with cancer are assessed for tobacco use and that those who use tobacco are connected to treatment, according to Lam.
“Oncologists or anyone on the cancer care team is prompted to ask the patient about their tobacco status, and those who smoke are advised to quit and then proactively connected to our smoking cessation program,” Lam said. “We ensure that patients with cancer who smoke do not fall through the cracks.”
In another study, published in Translational Behavioral Medicine, Ramsey and colleagues reported their EHR-Enabled Evidence-Based Smoking Cessation Treatment program led to 17% of patients with cancer who smoke receiving prescriptions for smoking cessation treatment, compared with 3% prior to the program.
Also, the percentage of patients assessed for tobacco use increased from 48% to 90% (P < .001).
“When we do not use our point-of-care approach and when we are not necessarily pushing smoking cessation treatment, we see about 10% to 15% of patients quit smoking,” Ramsey said. “When patients are not receiving smoking cessation treatment because they are not able or willing to accept it, even fewer patients quit — around 7%. However, when we are able to engage patients at the point of care, encourage them through brief advice and connect them to treatment options, including medication and technology-based approaches, about 30% of patients are able to quit smoking over the next 6 months.
“We are seeing a nearly threefold increase in cessation when patients with cancer who smoke receive some form of smoking cessation treatment, whether through medications or technology-based programs,” he added.
Other means of technology also have proved helpful. For instance, a study is underway at Fred Hutchinson Cancer Research Center — in collaboration with Seattle Cancer Care Alliance and its network sites and Memorial Sloan Kettering Cancer Center — to compare two novel smartphone apps for patients with cancer who smoke and plan to quit.
The study — Quit2Heal — provides patients with 24/7 access to expert guidance and support to help with smoking cessation.
“At the end of the day, oncologists want the best outcomes for their patients, including those who smoke,” Ramsey said. “When possible, it is important to promote the use of treatment because we see higher success rates with treatment.”
Westmaas agreed that in-house smoking cessation programs are effective but said various methods — including more technology-based approaches — must be made available to cater to individual patient preferences.
“Data show, depending upon which generation they are from, patients have different preferences for how they want to receive smoking cessation information and services,” he said. “For example, quit lines are more popular with older generations, whereas the younger generation may prefer email or texting programs. Having an arsenal of smoking cessation tools available certainly helps.”
‘The fourth pillar of cancer care’
In an invited commentary that accompanied the study by Cinciripini and colleagues, Fiore and colleagues described smoking cessation as “the fourth pillar of cancer care” along with surgery, radiotherapy and chemotherapy.
“The different recovery trajectories observed in former smokers and individuals who continue to smoke after diagnosis attest to the value in promoting cessation ... warranting its designation as the fourth pillar of cancer care,” Fiore and colleagues wrote.
Although developing in-house cessation programs and utilizing the EHR and other technologies may help improve cessation rates incrementally, widespread initiatives beyond those developed at individual institutions may be necessary to see dramatic changes.
For instance, Fiore and colleagues wrote that stakeholders including NCI, ASCO, American Cancer Society and Lung Cancer Roundtable should establish a consensus standard on the minimal levels of cessation care that should be provided. They also called for resources that foster the universal adoption of smoking treatment in cancer care and more funding for research on the long-term benefits of smoking treatment among patients with cancer.
Based on additional NCI funding to a second cohort of 20 centers in 2018, D’Angelo and colleagues plan to conduct additional analyses of tobacco treatment services among all 42 C3I-funded centers, including to evaluate whether disparities exist in the receipt of such services. Researchers also plan to look at whether centers are tracking patients’ use of e-cigarettes.
Overall, a shift in mindset in the cancer care community might need to occur, from treating smoking cessation as an extra step to considering it as part of treatment.
“Providers do not want to complicate an already overwhelming situation, and in this circumstance, they are not asking if people are ready to stop smoking but are going past this and basically saying as a matter of protocol that treating cancer includes treating tobacco dependence as a part of cancer care,” Leone said. “It is not an addition but is already a part of the cancer treatment protocol.” – by Jennifer Southall
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For more information:
Li-Shiun Chen, MD, ScD, MPH, can be reached at Washington University School of Medicine, 660 S. Euclid Ave., Box 8134, St. Louis, MO 63110; email: firstname.lastname@example.org.
Cho Y. Lam, PhD, can be reached at Huntsman Cancer Institute, 2000 Circle of Hope Drive, Room 4703, Salt Lake City, UT 84112; email: email@example.com.
Frank T. Leone, MD, MS, can be reached at University of Pennsylvania Medical Center, 51 North 39th St., Philadelphia, PA 19104; email: firstname.lastname@example.org.
Alex T. Ramsey, PhD, can be reached at Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8134, St. Louis, MO 63110; email: email@example.com.
J. Lee Westmaas, PhD, can be reached at American Cancer Society, 250 Williams St. NW, Atlanta, GA 30303; email: firstname.lastname@example.org.
Disclosures: Chen, Lam, Leone, Ramsey and Westmaas report no relevant financial disclosures.