WASHINGTON – A new policy statement aims to help cancer patients to quit using tobacco and encourage more physicians to consider tobacco use as a measure in trials and as a key vital sign.
"Today, we call on the oncology community in this statement to assess and document tobacco use by, and to provide cessation support to all cancer patients," Dr. Roy S. Herbst said at a press briefing April 9 at the annual meeting of the American Association for Cancer Research.
Dr. Roy S. Herbst
Dr. Herbst is a member of the AACR Tobacco and Cancer Subcommittee that wrote the statement, and chief of medical oncology at Yale Cancer Center and Smilow Cancer Hospital at Yale-New Haven in Conn.
The report’s two main recommendations:
• Patients with cancer, participants in cancer trials, and patients being screened for cancer and who use tobacco or who have recently quit, should be given evidence-based tobacco-cessation assistance, ideally within an oncology practice.
• Tobacco use should be comprehensively and repeatedly documented in all cancer patients – both in practices and in trials – so as to gauge the effect of tobacco on treatment, disease progression, comorbidities, and survival.
Addressing tobacco use is urgent because up to a third of all cancer-related deaths and 87% of lung cancer deaths are because of tobacco use, Dr. Herbst said. Tobacco use plays a role in 18 different cancers. Prevention is the goal, but it’s also important to urge people who have cancer – or who have survived it – to stop using tobacco, he said.
Patients who use tobacco have worse outcomes and more difficult treatment. According to the policy statement, tobacco use decreases the effectiveness of chemotherapies and interferes with drug metabolism. The data also shows that it decreases survival in cancer of the lung, head and neck, breast, prostate, colon, esophagus, cervix, bladder, and ovaries and in leukemia.
Evidence-based tobacco cessation models developed by the U.S. Public Health Service are endorsed by the AACR, the American Society of Clinical Oncology, and others, and yet few clinicians offer cessation services.
The AACR committee also reported that only 38% of National Cancer Institute–designated Cancer Centers record smoking as a vital sign and less than half have dedicated tobacco cessation personnel. And, in a survey by the International Association for the Study of Lung Cancer, only about 40% of lung cancer specialists said they discussed medication or offered cessation support to patients.
Tobacco assessment in cancer patients may be underperformed in part because of physician and patient perceptions that it’s too late to have an impact, Dr. Herbst said. "There is the feeling that someone’s smoking, they already have cancer, why worry about it."
There is also the issue of payment.
Smoking cessation generally has been not covered in the past, although Medicare covers up to eight visits a year for counseling. The Affordable Care Act requires coverage of tobacco cessation by all insurers starting in 2014.
"It’s true that reimbursement in the past was very poor," said Benjamin A. Toll, Ph.D., a psychiatrist and program director of the smoking cessation service at Smilow Cancer Hospital at Yale-New Haven. "It’s still not particularly high, but it’s getting better," he said, at the briefing.
Clinicians and researchers also have not been diligent about assessing tobacco use in trials. A survey of 155 NCI Cooperative Group Trials showed that only 29% of trials assessed tobacco use at enrollment; far fewer recorded smoking status during the trial. Less than 5% followed up subsequently on tobacco use status during or after the trial.
None of the studies evaluated nicotine dependence or the patient’s interest in quitting.
"It really is incredible that so many of these NCI trials are done and these data are not recorded," said Dr. Herbst.
"Assessing Tobacco Use in Cancer Patients and Facilitating Cessation" is the third statement on tobacco use by the AACR, published online in Clinical Cancer Research (2013;19:1-8).
The statement was Dr. Herbst reported that he received consulting fees from Biothera, Diatech, and Quintiles. Mr. Toll reported that he received support from Pfizer, for medicine only.
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