Washington, DC—Tobacco use among patients with cancer is an important but often overlooked issue that requires intervention by oncology practices. In recognition of the problem and the gap between the need for intervention and the services delivered, the American Association for Cancer Research (AACR) issued a policy on tobacco use at its 2013 annual meeting.
The genesis for the policy came from some surprising and disappointing survey results showing that many oncology practices do not routinely address tobacco use and that many clinical trials do not document tobacco use at baseline and follow-up, although it is a confounding factor.
In fact, tobacco use interferes with the efficacy of chemotherapy and radiation therapy, leads to worsened side effects from these therapies, increases the risk of developing a second cancer, and increases the risk of dying of heart disease. There is a strong rationale for creating infrastructure for delivery of evidence-based interventions to address tobacco use among patients with cancer.
The AACR policy states that only 38% of National Cancer Institute (NCI)-designated cancer centers that responded to a survey document smoking status as a vital sign, and less than 50% of these centers have dedicated personnel for tobacco cessation; by contrast, 78% of centers have dedicated nutrition personnel.
A different survey showed that whereas 90% of responding oncologists believe that tobacco use affects cancer outcomes and that tobacco cessation should be included as a standard of care, only 40% of these oncologists provide routine assistance for smoking cessation. Only 33% of lung cancer specialists considered themselves adequately trained in smoking cessation.
A recent study of 155 NCI Clinical Trials Cooperative Group Program trials demonstrated that only 29% of registered trials assessed tobacco use during the study. Less than 5% of these trials include follow-up on subsequent tobacco use status.
It is very difficult for people to quit smoking. Studies suggest that although approximately 50% of smokers try to quit, only between 4% and 7% are successful in doing so without evidence-based intervention.
“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,” said Roy S. Herbst, MD, PhD, Chair of
the AACR Tobacco and Cancer Subcommittee that produced the policy statement, and Chief of Medical Oncology, Yale Cancer Center and Smilow Cancer Hospital at Yale-New Haven, CT.
Evidence-based approaches to stop smoking include pharmacotherapy and nicotine chewing gum, as well as the “5A” approach to smoking cessation—ask about smoking status, advise people to quit, assess interest in quitting, assist with pharmacotherapy and counseling, and arrange follow-up. However, many cancer providers rarely advise patients on how to approach quitting.
The AACR’s policy statement endorses a number of recommendations to remedy this treatment gap. The statement notes that oncology practices should be responsible for providing assessment and intervention for patients with cancer who continue to smoke and for recent quitters. The recommendations call for:
- Repeat documentation of tobacco use in all patients with cancer, so that the confounding effects of smoking on treatment, disease progression, and comorbidities can be tracked in clinical trials, starting at registration and continuing through follow-up
- Tobacco use should also be documented in all clinical care settings; universal standardized measurements of tobacco use and of tobacco exposure are required to be able to make cross-center comparisons and to compile a meaningful database
- Researchers and healthcare quality and accreditation bodies should incorporate evidence-based criteria
- Healthcare systems, payers, and funding bodies should provide reimbursement for tobacco use interventions and should provide incentives for developing and for delivering interventions.
The Affordable Care Act provides for reimbursement for smoking cessation interventions by insurance plans by 2014, but this will vary by state and will be evidence-based. Electronic medical records will also track smoking status.