Tobacco Use in Cancer Patients: Often Overlooked but Critical to Address
One would hope that the importance of treatment for tobacco dependence would be well recognized as a cornerstone of standard care for cancer patients. However, a policy statement released by the American Association for Cancer Research (AACR) at its recent Annual Meeting revealed some surprising and disappointing findings related to the paucity of services and interventions for tobacco dependence in oncology practices and the lack of documentation of smoking status by oncologists and in clinical cancer trials.
The AACR statement, published in Clinical Cancer Research,1 calls on the oncology community to provide evidence-based tobacco-dependence treatment for all cancer and cancer-screening patients and to evaluate tobacco as a confounding factor in cancer clinical trial outcomes.
Here are some of the findings:
A survey of NCI-designated cancer centers found that only 38% of responding centers document smoking status as a vital sign and less than 50% have dedicated personnel for tobacco-dependence treatment, while 78% of the same centers have dedicated nutrition personnel.
A recent large survey of oncologists showed that while 90% believe that tobacco use affects cancer outcomes and that tobacco-dependence treatment should be included as standard of care, only 40% provided routine assistance for treating tobacco dependence. Only 33% of lung cancer specialists considered themselves adequately trained in smoking cessation.
A recent evaluation of 155 NCI Cooperative Group trials demonstrated that only 29% of registered trials assessed tobacco use during follow-up. Less than 5% of these trials included follow-up on subsequent tobacco use status.
In 2010, about 69% of smokers in the general public reported a desire to quit smoking, and more than 52% attempted to quit over the previous 12 months. Without use of evidence-based pharmacotherapy and/or counseling support, only about 4% to 7% of people are successful at quitting. These percentages are similar in cancer patients, explained Roy Herbst, MD, PhD, Chair of the panel that produced the AACR policy statement on Tobacco Use by Cancer Patients and Facilitating Cessation, and chief of medical oncology at Yale University School of Medicine in New Haven, Connecticut.
“Although lung cancer first comes to mind as associated with tobacco use, tobacco is implicated in 18 other cancers. A frequent assumption is that once cancer develops, it is fruitless to stop smoking. This is not true!” he Dr. Herbst emphasized.
Even though many cancers have effective treatments, tobacco use complicates treatment and reduces survival in lung, head and neck, breast, prostate, colon, cervical, and endometrial cancer as well as lymphoma, he continued. Tobacco use interferes with drug metabolism, compromises the effects of chemotherapy and radiation, leads to worse side effects from therapy, increases the risk of second cancers, affects wound healing, and exacerbates pain, he added.
“Patients who continue to smoke are at greatly increased risk of second cancers and heart disease. In addition to documenting what drugs patients are taking, we also need to document if they are smoking and whether this is related to other health problems they have,” he told the audience.
A strong evidence base supports use of pharmacotherapy and nicotine chewing gum, as well as the “5A” approach to treating tobacco users (ie, ask about smoking status, advise people to quit, assess interest in quitting, assist with pharmacotherapy and counseling, and arrange follow-up). Yet many cancer health-care providers never get beyond the first 2 As, Dr. Herbst said.
AACR’s policy statement makes concrete recommendations related to assessment of tobacco use and providing evidence-based treatment for current smokers and recent quitters, as well as all participants in clinical trials of cancer, and cancer screening patients. The statement says that oncology practices are responsible for ensuring that such care is delivered.
The statement calls for the repeated documentation of tobacco use in all patients, so that the confounding effects of smoking on treatment, disease progression, and comorbidities can be tracked in clinical trials, starting at registration and through follow-up. Tobacco use should also be documented in all clinical care settings. Universal standardized measurement of tobacco use and exposure is needed to create a meaningful database for information-sharing.
Further, evidence-based tobacco interventions should be incorporated into review criteria for researchers as well as health-care quality and accreditation bodies. And tobacco cessation interventions should be valued and supported by health systems, payers, and funding bodies by providing incentives for developing infrastructure and delivering interventions.
At a press conference where the policy statement on tobacco use and cancer patients was presented, Carolyn Dressler, MD, Center for Tobacco Products (FDA), Rockville, Maryland, said that the Affordable Care Act stipulates that smoking cessation interventions will be covered by all insurance plans, but this will vary by state and be evidence-based. Electronic medical records, also a new requirement, will track smoking status. ■
Disclosure: Drs. Dressler and Herbst reported no potential conflicts of interest.
1. Toll BA, Brandon TH, Gritz ER, et al: Addressing tobacco use by cancer patients and facilitating cessation: An American Association for Cancer Research Policy Statement. Clin Cancer Res 19:1941-1948, 2013.
Richard Hurt, MD, Director of the Nicotine Dependence Center at the Mayo Clinic in Rochester, Minnesota, applauds the new American Association for Cancer Research (AACR) policy recommendations.
“It is disappointing that more oncologists are not paying enough attention to tobacco use in their...