A Call for Tackling Smoking Cessation in Cancer Patients

Peter G. Shields, MD

Deputy Director, The Ohio State University Comprehensive Cancer Center

Thoracic Oncologist, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute

Columbus, OH

Smoking among cancer patients remains a significant and concerning problem that the oncology community has traditionally struggled to overcome. Although the entire medical community recognizes the importance of smoking cessation— both for cancer prevention and cardiopulmonary health—supporting patients in their efforts to cease smoking is generally not done well.

Nationwide, it is estimated that up to 30% of smokers who receive a cancer diagnosis, depending on the cancer type, continue to use tobacco despite all the scientifically backed arguments we throw at them for why ditching the habit is the only logical choice. In my lung cancer practice, about 50% of my patients are still smoking when they begin treatment.

But that is the thing about tobacco use: Choosing to use tobacco is not a decision based in logic. First and foremost, it is important for all of us who treat patients with cancer to acknowledge that tobacco addiction is a real and difficult phenomenon to overcome. For many people, smoking is a lifelong habit that provides comfort and stress relief. We are asking them to abandon this habit—immediately and completely—at one of the most stressful times of their lives: being diagnosed with cancer.

The habit becomes an addiction and to overcome this addiction many smokers will need pharmacotherapy and at least brief counseling to achieve longterm quitting. It also requires a dual commitment of accountability with both the patient and the treating medical team.

This is where the medical community has failed to support patients in eliminating one of the most common causes of preventable death worldwide—and the oncology community has the opportunity to lead changes in practice that could result in thousands of lives being saved each year.

Implications for Cancer Treatment

Tobacco-related diseases are the most preventable cause of death worldwide. Smoking cessation leads to improvement of cancer treatment outcomes as well as decreased recurrence and reduced toxicity. It is estimated that more than 25% of the cancer related deaths in the United States will be caused by tobacco smoking.¹

In the cancer patient population specifically, science has shown us that smokers with cancer have a high level of dependence and smoking cessation leads to improvement in cancer treatment effectiveness and decreased recurrence. Published data illustrate that smoking influences the metabolism of chemotherapy and certain targeted agents by altering drug clearance time and plasma concentration, which can potentially impact drug efficacy. Smoking is also known to increase the risk of radiation therapy— associated treatment complications and decrease treatment response. The habit is also associated with increased risk of postoperative complications and mortality after surgery, including more pain/fatigue when compared with nonsmokers, impaired wound healing, increased infection rate, and pulmonary complications.^2-4

New NCCN Guidelines

Recognizing a critical gap in support for patients with cancer and an opportunity to prevent future cancers, the National Comprehensive Cancer Network (NCCN) published the first evidence-based NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Smoking Cessation in a cancer patient population in March 2015.

The intention of the NCCN Guidelines Panel for Smoking Cessation, which I chaired, was to give oncologists a roadmap for successfully supporting patients in their tobacco cessation goals. The guidelines are a strong start, but every institution’s clinical model runs differently. To successfully integrate smoking cessation as an integral component of the care model, oncology teams will need dedicated staff and resources and an operational plan to make the smoking cessation services an easy-to-implement priority versus an afterthought.

Cessation Plan Elements

Based on a review of scientific literature and practical clinical experience of the 26 NCCN member organizations, the NCCN panel recommends that all treatment plans for smokers with cancer include: evidence-based pharmacotherapy, behavior therapy (counseling), and close follow-up with retreatment as needed.

The two most effective pharmacotherapy agents are nicotine replacement therapy and varenicline. These therapies can be combined as needed, based on the patient’s situation. However, to be effective, these have to be used with some counseling about the benefits of cessation and the barriers to quitting, just as we advise patients on how and when to use narcotics for pain control.

Combining pharmacology therapy and counseling has been shown to yield the best results for smoking cessation. High-intensity behavior therapy with multiple counseling sessions is preferred for maximum effectiveness but a minimum, brief counseling is highly important.

Furthermore, smoking status should be documented in the patient’s health record and updated at regular intervals to indicate changes in smoking status, quit attempts made, and interventions utilized. Smoking relapse and brief slips are common and should be expected. By documenting changes in smoking status/attempts to quit in the medical record, medical staff will be able to keep the conversation going about smoking cessation and provide additional guidance and interventional supports to help the patient through his or her attempts to quit. This additional follow-through on the clinical practice side is absolutely critical for long-term cessation. In addition to outlining a general approach to smoking cessation during cancer treatment, the full NCCN guidelines for smoking cessation, available for download at nccn.org, provide specific recommendations on steps for evaluation and assessment of patients within two distinct categories: current smokers (smoked within the past 30 days), and former smokers and recent quitters (more than 30 days since last smoked).

We also provide an in-depth list of community resources to support oncologists and their patients in successful smoking cessation, including mobile apps and online support for patients and additional resources to guide healthcare practice.

As oncologists, we must be the leaders in developing a model for smoking cessation that works if we are going to make progress in reducing preventable cancer deaths. I encourage you to embrace this approach to smoking cessation with your own patient population. We are actively working on a plan to retool our clinical model to incorporate this type of comprehensive smoking cessation support at The OSUCCC—James. Be creative, be aggressive, and move the needle on preventable cancer deaths by providing the important—but often overlooked—support patients need to overcome tobacco addiction.

References

1. US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. http://www.surgeongeneral.gov/library/reports/ 50-years-of-progress/#execsumm. Published January 2014.
2. O’Malley M, King AN, Conte M, et al. Effects of cigarette smoking on metabolism and effectiveness in systemic therapy for lung cancer. J Thorac Oncol 2014;9(7):917-926.
3. Hamilton M, Wolfe, JL, Rusk J, et al. Effects of smoking on the pharmacokinetics of erlotinib. Clin Cancer Res. 2006;12(7 Pt 1):2166-2171.
4. Van der Bol JM, Mathijssen RH, Loos WJ, et al. Cigarette smoking and irinotecan treatment: pharmacokinetic interaction and effects on neutropenia [published online June 11, 2007]. J Clin Oncol.