When patients who smoke begin cancer treatment at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis – or at any of Siteman’s satellite locations – they also now receive advice about quitting smoking, referrals to easy-access smoking-cessation services and, if suitable, prescriptions for medications that aid in kicking the habit.
Those early-intervention steps are yielding promising results.
When patients with cancer quit smoking, it can prolong life, and prevent recurrence and the advent of secondary cancers.
The program saw nearly twice as many cancer patients get assessed for their smoking status.
In the five months before the program launched, some 48 percent of the more than 34,000 patients treated at Siteman were asked whether they smoked.
This compares with 90 percent of the more than 24,000 patients who were asked if they smoked in the five months after the program began.
The percentage of patients referred to treatment also increased.
In the five months before launch, only .72 percent of smokers were referred to behavioral counseling, and only 3 percent were prescribed medication to help them quit.
In the months after the program began, the percentage referred to counseling nearly tripled to 1.91 percent, and the percentage of smokers prescribed medication to help them quit increased almost fivefold to 17 percent.
The results are published July 17 in the journal Translational Behavioral Medicine.
“This is a paradigm shift from the more traditional approach, in which we would refer cancer patients to specialists and hope these very sick patients would find the time, the motivation and the transportation to get help from such a specialist,” said first author Alex T. Ramsey, assistant professor of psychiatry.
“Helping cancer patients quit smoking is one of the most important things we can do.
So it’s important we provide smoking-cessation treatment in ways our patients can take advantage of.”
The new Siteman program, available on the Washington University Medical Campus and at Siteman locations in West County, St. Charles County, South County, North County and in Illinois, is funded through the National Cancer Institute’s Cancer Center Cessation Initiative.
In 2018, School of Medicine researchers received a grant to fund the interventional approach as part of the Cancer Moonshot Initiative.
The key goal of the grant has been to develop strategies to reduce smoking among cancer patients.
When the program was launched in 2018, the smoking rate among adults in Missouri was 22 percent; in Illinois, the rate was 16 percent.
But among patients from those two states who were treated at Siteman, 23 percent were smokers.
Ramsey said it’s too early to tell how many of the smokers in the program have kicked the habit. It’s also not possible to tell yet which specific approaches to quitting work best.
“It takes most people several attempts before they quit smoking successfully,” he said. “The key now is to keep providing opportunities to quit and offering new approaches when a quit attempt fails.
Our next step will be to go back and look at which types of treatment work best.”
The key, according to the project’s principal investigator, Li-Shiun Chen, MD, is to remind patients and doctors that even very sick cancer patients can improve their health if they quit or cut back on tobacco use.
“Quitting smoking ensures the best treatment outcomes for people with cancer,” said Chen, an associate professor of psychiatry and a research member at Siteman.
“Our idea is to find out which patients are smokers and to offer assistance to every single one of them.”
Chen and Ramsey expect that as the months and years pass, and more people get medication or counseling to help them quit, the number of ex-smokers seen at Siteman will rise, and outcomes for those patients will improve.
Now, however, the program is in its infancy, Ramsey said.
“It’s very promising, but it’s only a first step,” he said. “We doubled assessment rates, and we saw five times more people taking medication to stop smoking.
On the other hand, the absolute numbers are still smaller than we’d like.
But this study assessed the first five months of the program, and we’re continuing to improve and extend our ability to reach more patients.
I think that bringing this treatment support to clinics and hospital settings, at a time when patients are highly motivated to quit smoking, is going to pay big dividends.”
The early detection of cancer, due to improved diagnostic modalities, and development of more effective treatments has contributed to the increase in the overall cancer survival rate.
The overall 5-year survival rate for all cancers rose from 49% in 1975–1977 to about 68% in 2002–2008, according to the most recent available data.1
This increase in survival rates highlights the importance of caring for survivors, but also suggests further work is needed in cancer prevention, particularly for modifiable risk factors like smoking.
Smoking accounts for at least 30% of all cancer deaths and nearly 90% of lung cancer deaths.1–3
Almost 62% of all recently diagnosed cancer patients are reportedly current smokers, recent quitters (quit within the last 12 months), or former smokers; with the highest proportions of current smokers, recent quitters, or former smokers in patients with lung or head and neck cancer.4
Smoking cessation and relapse prevention represent an important opportunity to improve cancer survival rates,5 reduce the risk of cancer treatment complications,6 and improve the quality of life of cancer patients and survivors.7
After a continuous decrease in smoking rates over several decades, the overall smoking prevalence in the US has remained nearly constant for the past several years despite the widespread knowledge that smoking and tobacco use cause cancer as well as cardiovascular, pulmonary, and several other deadly diseases.8
Close to half a million Americans die each year from smoking-related illnesses.9
In one national survey in 2010, an estimated 69.6 million Americans aged 12 years or older were current users of a tobacco product (i.e., had used tobacco in the past month), confirming that tobacco is one of the most widely used substances in the United States (US).
Among these tobacco users, 58.3 million (23.0% of the population above the age of 12) were current cigarette smokers, 13.2 million (5.2%) smoked cigars, 8.9 million (3.5%) used smokeless tobacco, and 2 million (0.8%) smoked pipes.10 On the other hand, the most recent yearly report of the Centers for Disease Control and Prevention (CDC) estimates that 42.1 million people, or 18% of all adults (aged 18 years or older), in the United States are still smoking cigarettes and that cigarette smoking is more common among men (20.5%) than women (15.8%).11
Other national surveys estimate that 70% of smokers in the US say they want to quit and 50% have tried to quit at least once in the preceding year.12
Unfortunately, almost all (95%) of those who tried to quit on their own relapse,12 usually in the first week.
This attests to the chronic relapsing nature of nicotine dependence and difficult-to-reverse brain neuroadaptations that take place as a function of years of nicotine exposure.13
Among lung, head and neck, and bladder cancer patients as well as survivors, prognosis, tumor site, and the impact of cancer treatment itself seem to influence smoking cessation rates.14–17
A poorer prognosis does not usually motivate patients to quit, but a cancer site that is clearly attributable to smoking does, especially if patients have a favorable survivorship prognosis.
In addition, the nature of the cancer treatment required affects the ability to smoke—for example, the need to avoid smoking before surgery or a hospitalization that would limit patients’ ability to smoke.
Still, in the long run, there do not seem to be significant differences between smoking rates in cancer survivors and the general population.
In one survey, almost 20% of cancer survivors reported being current smokers, with a high rate of 43% of cancer survivors younger than 40 years reporting current smoking.18
The overall prevalence of current smoking among cancer survivors is around 23% during the first year after diagnosis.19
After that period, abstinence from smoking drops gradually, suggesting that the first year after diagnosis is a crucial time for relapse prevention interventions.20
The pool of individuals who could be helped by such interventions may be even larger since some current smokers may be among those who self-identify as “recent quitters” but could be identified as current smokers using biologic measures for confirmation of abstinence.
Indeed, self-reports of tobacco use (smoking) status in one study with head and neck cancer patients was shown to be underestimated in comparison to rates obtained using biologic corroboration of smoking status.21
In another study, recently diagnosed cancer patients who self-identified as “recent quitters” were 12 times more likely to have their report be discordant with cotinine verification (34.5% discordant) than those who reported being “former smokers” (2.8% discordant).22
Remarkably, apart from disease site and stage, abstinence from smoking is the strongest predictor of survival in cancer patients who have ever smoked.
As a group, current smokers, former smokers, and recent quitters have poorer survival outcomes than never smokers.23
In a cohort of 5185 cancer patients at one institution, smoking at the time of cancer diagnosis was found to be associated with higher 5-year overall and disease-specific mortality rates than those of recent quitters, former smokers, and never smokers.
In that study, with a minimum of 12 years of follow-up but without biochemical verification, current smokers had a higher overall mortality risk compared to recent quitters hazard ratio (HR) = 1.17, (95% CI, 1.03–1.32), former smokers HR = 1.29, (95% CI, 1.17–1.42), and never smokers HR = 1.38, (95% CI, 1.23–1.54) in the cohort. Further, current smokers had a higher disease-specific mortality (DSM) risk than former HR = 1.23, (95% CI, 1.09–1.39) and never smokers HR = 1.18, (95% CI, 1.03–1.36).4
In recent years, screening for tobacco use in cancer settings has been emphasized,24 while progress have been made, more system wide changes need to be done to reach universal screening.25,26
In addition, the provision of tobacco cessation treatment for identified tobacco users is still not widely available.
In a recent survey of oncology providers, less than half of tobacco users were offered tobacco cessation treatment.27
This gap is an area of cancer care that requires improvement as it can bring both long term (survival) as well as short term benefit to the patient in terms of improved treatment outcomes.28
Multiple retrospective studies have been done on the impact of continued smoking on cancer treatment; although some are of small sample sizes, all have shown the deleterious impact of continuing to smoke in cancer patients.5
These retrospective studies have focused mostly on smoking-related cancers such as lung,29,29–39 head and neck,40–45 esophagus,46 hematologic (leukemia),47,48 bladder,49,50 colon,51 and breast cancers.52–54
Other, prospective studies that were also done to show the impact of continued smoking on cancer treatment have produced similar findings in cancers of the head and neck,23,43,55–60 oropharynx,61 lungs,7,62 prostate,63 and breast.64
Collectively, these studies support the notion that tobacco cessation improves treatment outcomes in cancer patients and highlight the importance of providing tobacco cessation services to cancer patients and survivors.
Not to do so can have negative clinical implications as patients who continue to smoke during the course of their cancer treatment have higher risks of complications, of developing secondary cancers, and of death.65
A wide body of literature supports the role of tobacco in carcinogenesis5 and, as detailed above, the impact of tobacco on cancer treatment.
The impact of continuing to smoke on survivorship is also grim.
In a review of 10 studies, Parsons et al. found that people who continue to smoke after diagnosis of early-stage lung cancer almost double their risk of dying.66
In a study of 611 small-cell lung cancer patients, the risk of all second cancers (mostly non–small-cell cancers of the lung) was increased by 3.5-fold [relative risk (RR) of 3.5 (CI, 2.8–4.3)], compared with the general population.
This translated to 327 excess cancers per 10,000 person-years among those patients who had any smoking history (who were ex-smokers, recent quitters or current smoker).
Further, the risk of a second lung cancer was also increased RR=13 (95% CI, 9.4–17), in those patient (compared with never smokers) who received chest radiation; while that risk of second lung cancer increased to a lesser extent RR=7 (95% CI, 2.9–13) those patients if did not receive chest radiation.
An interaction between chest radiation and continued smoking resulted in the highest risk RR=21 (95% CI, 13–32).67
In addition, in other studies cancer patients who were active smokers during cancer treatment had lower response rates to radiation therapy than former smokers and recent quitters who stopped smoking before starting treatment.57,58
Common side effects of radiation such as oral mucositis, xerostomia, weight loss, and fatigue were reported as exacerbated by cigarette smoking.68
Smoking also affects the liver metabolism of many chemotherapeutic agents, thereby often decreasing the response to chemotherapy and increasing the rates of complications.69
Continued smoking also increases the risk of complications in patients who require surgical intervention.
In a meta-analysis on the topic, several end points were separately evaluated.
In 19 unique studies comprising 7616 unique patients, cigarette smoking was found to increase the risk of necrosis of wound and tissue, with an odds ratio (OR) of 3.61 (95% CI, 2.78–4.68).
The end point of healing delay and dehiscence was evaluated in 18 studies comprising 26,297 patients, with an OR of 2.86 (95% CI, 2.78–4.68).
Surgical site infection was an end point in 51 unique studies comprising over 400,000 patients, with an OR of 2.12 (95% CI, 1.56–2.88)70; further, in plastic surgery tissue ischemia and wound-healing impairment are related to continued tobacco use versus abstinence.71
In addition to higher morbidity and mortality rates, cancer survivors who are former smokers/recent quitters or current smokers score lower on quality of life indices than survivors who have never smoked.7,33
Moreover, in two studies of lung cancer survivors and one in head and neck survivors, those who quit smoking prior to their cancer diagnosis (recent quitters and former smokers) were likely to perform better on quality of life indices than survivors who continued smoking or quit smoking after their cancer diagnosis.33,72,73
Cancer survivors who continued to smoke generally also had poorer physical health, self-perception of their general health, emotional and social functioning, and vitality than survivors who were never smokers or former smokers.33,72,73
A causal relationship between smoking and the diagnosed cancer seems to help motivate patients to quit smoking.
Smokers with certain cancers clearly related to smoking, such as lung or head and neck cancer, reportedly often quit smoking as an immediate response to their diagnosis and are even more likely to quit when told that their cancer is related to smoking16; however, the recidivism rates remain high.20
Although the concept of addiction (compulsive use of tobacco despite adverse consequences) has not been studied in cancer patients, addiction is thought of as a universal concept of a brain disorder74 that affects cancer patients similarly as any other chronic disease would impact them, such as hypertension, asthma or type-2 diabetes.
Like addiction, these chronic diseases have behavioral and biological components and require pharmacological treatment and lifestyle changes to manage the disease or sustain remission.75
Therefore, clinicians are urged to be on the lookout for delayed relapses.
And they should address smoking behavior and history on an ongoing basis by conceptualizing smoking (repeated tobacco use) as a chronic and relapsing disorder,76 in contrast to the way acute disorders (e.g., infectious disease) are viewed, and by anticipating and normalizing setbacks.
In the area of tobacco cessation there are only a few well-designed prospective studies focused on cancer patients, with about half concentrating on nurse delivered intervention.77
A recent meta-analysis on the topic concluded that heavy smokers and those in the perioperative period did benefit from a cessation intervention.
Although, the authors reported that in the overall providing smoking cessation intervention to cancer patients did not seem to improve cessation rates.
This may be due to lack of homogeneity among the pooled studies, as they had different measures for smoking and abstinence, they included different types of cancer site and cancer patient populations (out-patients only or inpatients only).78
More information: Alex T Ramsey et al. Care-paradigm shift promoting smoking cessation treatment among cancer center patients via a low-burden strategy, Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment, Translational Behavioral Medicine (2019). DOI: 10.1093/tbm/ibz107
Journal information: Translational Behavioral Medicine
Provided by Washington University School of Medicine in St. Louis
