It is well established that smoking increases the risk for developing cancer, but when it comes to tobacco cessation in the cancer survivor population, should oncologists be stepping in, and what resources should they be using? Graham W. Warren, MD, PhD, posed these questions to the audience at the 2018 ASCO Cancer Survivorship Symposium in Orlando,1 and he offered his own evidence-based insights on establishing successful tobacco cessation programs in this patient population.
What We Know About Survivors and Smoking
The 2014 Surgeon General’s Report was the first large body of evidence on the effects of tobacco in patients with cancer.2 According to outcome estimates from the report, current smoking increased overall mortality by a median of 51% and cancer-related mortality by a median of 61%. “And this isn’t just a head and neck or lung cancer problem,” noted Dr. Warren, Vice Chairman for Research in Radiation Oncology and the Department of Cell and Molecular Pharmacology, Hollings Cancer Center, Medical University of South Carolina, Charleston. “This is a common theme across cancer.”
So even in highly curable cancers that we don’t necessarily associate with smoking, smoking cessation may be of tremendous benefit. Getting people to quit smoking may improve survival.— Graham W. Warren, MD, PhD
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In cancer patients and survivors, the evidence is sufficient to infer a causal relationship between cigarette smoking and adverse outcomes, including increased all-cause mortality, cancer-specific mortality, and risk for second primary cancers. The evidence is suggestive, but not sufficient, to infer a causal relationship between cigarette smoking and cancer recurrence, poorer response to treatment, and increased treatment-related toxicities, he added.
Smoking cessation is not typically a major concern in prostate cancer, but one study of patients with prostate cancer showed that although less than 10% died of their cancer, 90% died of something else—such as cardiopulmonary disease, gastrointestinal cancer, or lung cancer—with sizable hazard ratios for increased risk of these causes in current smokers.3
“So even in highly curable cancers that we may not necessarily associate with smoking (ie, breast, prostate), smoking cessation may be of tremendous benefit,” he said. “Getting people to quit smoking may improve survival.”
What’s Being Done
Surveys have shown that about 90% of oncologists ask their patients about tobacco use, and 80% advise patients on the importance of quitting, but only about 30% to 40% discuss medications and actively assist patients in quitting.4 Typically, this figure is cut in half when patients are asked about their clinical experience. Only about 15% to 20% report receiving any assistance from their oncologists in trying to quit smoking, he said.
Dr. Warren and his colleagues sought to explore the barriers preventing oncologists from providing cessation support and found the predictive variables to be lack of time, lack of resources, and lack of expertise.5 However, a survey of oncologists at National Cancer Institute–designated cancer centers revealed that the majority of oncologists wanted cessation assistance to be provided by clinical staff other than themselves.6 “This is important because this helps narrow it down to time and resources.”
Moving Smoking Cessation Into Practice
At Roswell Park Cancer Institute, Dr. Warren and his colleagues developed an automated tobacco assessment and cessation program for patients with cancer.7 They screened about 12,000 patients and referred about 2,700 by placing cessation calls or sending out mailings. They were able to contact about 81% of the patients they called, but of 1,381 patients who received a mailing, less than 2% contacted the program. “So mailing doesn’t work for me,” he said.
Any patient who has smoked within the past 30 days should be offered referral.— Graham W. Warren, MD, PhD
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They found that three questions captured 99% of patients who needed a cessation referral: “Do you now smoke cigarettes every day, some days, or not at all?” “Do you currently use any other tobacco products?” and “About how long has it been since you last smoked a cigarette, even a puff?”
“If you only get to ask one question, ask the last one,” he added. “You can find about 90% to 95% of people in need of cessation support with this one question. Any patient who has smoked within the past 30 days should be offered referral.”
The researchers also found that extending this assessment to once a month delayed cessation referral for less than 1% of patients. He cautioned clinicians to avoid asking about tobacco use at every single visit, as this creates a burden on both staff and patients.
A common concern expressed by administrators is the cost of these programs. “But how many people fail [to respond to] first-line cancer treatment because of smoking?” he posited.
We’ve got to change what we’re doing: We’ve got to train differently, think differently, and use the resources available.— Graham W. Warren, MD, PhD
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To answer that question, Dr. Warren and his colleagues built a model. Assuming a 30% baseline failure rate (in nonsmoking cancer patients), a smoking risk of 1.6 (from the Surgeon General’s Report), a $100,000 second-line cost of cancer treatment, and a smoking prevalence of 20% among 1.6 million cancer patients, the cost of next-line cancer treatment comes to $3.4 billion per year in the United States. “So the costs associated with tobacco use seem to be significant,” he said.
Bringing the Research to Patients
“If you talk to patients about quitting and they keep smoking, don’t look at them in a stigmatizing manner,” he cautioned. “I’ve had people tell me they started when they were 4 years old and have a 267 pack-year history. When you start smoking as a kid and smoke for 40 to 60 years and then you get cancer, it’s exceptionally difficult to quit.”
After utilizing a standardized screening process to identify tobacco use, Dr. Warren’s institution has seen impressive participation rates when cessation programs are offered to all patients delivered via phone onsite (70%–80% participation), but appear to have lesser participation in person on site or with interactive voice recorder–based programs, although these methods may suit certain institutions. He does not, however, suggest implementing a mailing or provider-delivered program as the only resource for patients. “You can do those things, but you’ll face enormous lack of contact,” according to Dr. Warren.
He urged providers to look at how tobacco affects the entire continuum of cancer risk and diagnosis and to “Ask, Advise, and Refer.” Dr. Warren also stressed the importance of engaging with primary care physicians to optimize the treatment timeline, empower patients to take steps toward quitting, and ensure they are receiving the support they need. “The primary care message is simple: Now is the time to try and quit smoking, and I can help,” he said.
“We have the opportunity to approach a common theme that might make a huge difference to a lot of patients, but we have to do it in a sustainable manner,” he added. “So we’ve got to change what we’re doing: We’ve got to train differently, think differently, and use the resources available.” ■
DISCLOSURE: Dr. Warren reported no conflicts of interest.
2. U.S. Department of Health and Human Services Centers for Disease Control and Prevention: The Health Consequences of Smoking–50 Years of Progress: A Report of the Surgeon General. National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
3. Bittner N, Merrick GS, Galbreath RW, et al: Primary causes of death after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 72:433-440, 2008.
4. Warren GW, Marshall JR, Cummings KM, et al: Practice patterns and perceptions of thoracic oncology providers on tobacco use and cessation in cancer patients. J Thorac Oncol 8:543-548, 2013.
5. Warren GW, Dibaj S, Hutson A, et al: Identifying targeted strategies to improve smoking cessation support for cancer patients. J Thorac Oncol 10:1532-1537, 2015.
6. Pommerenke A, Alberg A, Brandon TH, et al: Physician preferences in tobacco cessation support for cancer patients: A survey of physicians at National Cancer Institute Designated Cancer Centers. 2014 AACR Annual Meeting. Abstract 5049.
7. Warren GW, Marshall JR, Cummings KM, et al: Automated tobacco assessment and cessation support for cancer patients. Cancer 120:562-569, 2014.