WASHINGTON—Despite their diagnosis, many cancer patients are so addicted to tobacco that they go right on smoking even if they wish to stop. So said Roy S. Herbst, MD, PhD, Chair of the American Association for Cancer Research's Subcommittee on Tobacco and Cancer, speaking at a news briefing at the AACR Annual Meeting here.
AACR has issued a policy statement calling for all cancer patients to be assessed for smoking regardless of their treatment setting and offering smokers guideline-based cessation programs to help them quit. The statement, now available online ahead of print in the AACR journal Clinical Cancer Research (doi: 10.1158/1078-0432.CCR-13-0666), also calls for evaluation of tobacco use as a cofounder in study subjects participating in clinical trials.
The AACR statement comes at a time when the Obama administration has just released a fiscal year 2014 budget that proposes raising the tax on tobacco products, a strategy known to encourage quitting (see box).
“With this statement, we call on all oncology professionals to take responsibility for identifying tobacco users at every visit and ensuring that these patients get the treatment and support they need,” AACR Chief Executive Officer Margaret Foti, PhD, said in a news release.
“For tobacco users who have developed cancer, patients and their physicians may act as if it is too late for tobacco cessation to provide meaningful benefit. Fortunately this is not true,” the AACR statement notes.
Indeed, said Herbst, Chief of Medical Oncology at Yale Comprehensive Cancer Center, for most cancer patients, it is not too late to help them quit. He stressed that a nihilistic view on the part of patients and their physicians is unwarranted—especially with the growing number of cancer survivors. “It's a tragedy if we successfully treat a patient's breast cancer, for example, and she comes back a few years later with lung cancer,” he noted.
He pointed out that smoking is responsible for some 30 percent of all cancer-related deaths—in 18 different cancers—as well as 87 percent of all lung cancer-related deaths. In all, tobacco caused an estimated 169,000 deaths in 2009 (the most recent year for which data were fully available), according to AACR figures. And, he noted, cancer survivors who continue to smoke put themselves at higher risk of premature death due to cardiovascular disease as well as second malignancies—an especially troubling fact in patients diagnosed with potentially curable early-stage cancers.
Herbst said that while he always takes a smoking history when seeing patients, unfortunately not all oncologists do. According to AACR statistics, only 38 percent of National Cancer Institute-designated Comprehensive Cancer Centers record smoking as a vital sign—and these centers are known for providing state-of-the-art care. Fewer than half of these centers have dedicated tobacco-cessation personnel (78 percent of the same centers have dedicated nutrition personnel).
Only 40 percent of lung cancer specialists surveyed discuss smoking-cessation medication or offer cessation support to their patients, while only 33 percent of the same surveyed personnel consider themselves adequately trained in smoking cessation.
Just as troubling as not offering cancer patients smoking-cessation advice—and not often discussed—said Herbst, is the fact that tobacco as a confounder is not adequately considered in clinical trials. Tobacco use can lead to “increased complications, treatment-related toxicity, poor wound healing, and different drug metabolism”—all of which can affect clinical trial results.
He said that in his own experience, he has found that smoking can affect the efficacy of erlotinib in lung cancer patients. “All oncology clinical trials should evaluate tobacco use,” he said. In the clinical trial setting, “we can't study tobacco without measuring it,” he added.
But in a survey of 155 NCI cooperative group trials only 29 percent of these trials assessed tobacco use at enrollment, and less than five percent followed up subsequently on tobacco use status. Thus the AACR statement calls for the development of universal standards for measurement of tobacco use and exposure in research settings as well as in clinical practice.
Asked by OT why smoking status is not routinely assessed during clinical trial accrual, since tobacco use can be a trial confounder, Herbst said, “It really is incredible.” He added, “We need to change the paradigm,” so that smoking status is assessed and measured in all clinical trial participants.
Also speaking at the news briefing, Benjamin Toll, PhD, Program Director of the Smoking Cessation Service at Smilow Cancer Hospital at Yale-New Haven and Chair of the writing committee that produced the AACR policy statement, said, “Many of the people I treat still continue smoking.”
He estimated that about 10 to 20 percent of cancer patients continue smoking: “It's not because they're weak,” he emphasized. “It's not voluntary. It's an addiction. They all tell me they want to quit.” But, he said, noting that tobacco has both physical and psychological factors, “Most people who try to quit fail.”
Toll emphasized that most smokers need to receive continued cessation treatment and follow-up, since few are able to quit on their first try. He said the quit rate for smokers at his center is about one-third. “These services should be part of standard care,” he said. “Smoking status should be assessed at every visit.”
Toll noted that while smoking cessation, done right, takes time and resources, “tobacco treatment pays dividends,” because it cuts down on disease and premature death. He said using an electronic medical record is a more rigorous way to track smoking status than paper records are.
Reimbursement for Smoking-Cessation Programs
And while reimbursement for smoking-cessation services has traditionally lagged, it is getting better, Toll said. The Affordable Care Act will cover smoking-cessation programs starting next year, although that will be done on a state-by-state basis.
Both Herbst and Toll said that it is difficult for a smoker to contemplate quitting when receiving a cancer diagnosis—because the fact of having cancer is so stressful and many people smoke to relieve stress.
“I see patients who are getting that diagnosis,” said Toll. “I ask them the amount they are smoking and what they like about it. I try not to use the term ‘quit’ in the first meeting because it's very daunting.” Often, he said, he tries to get a cancer patient who smokes to come back with a spouse if the spouse also smokes. That way, he said, it may be possible to get both the patient and the spouse into a cessation program.
The statement's other coauthors in addition to Toll (first author) and Herbst are Thomas H. Brandon, Ellen R. Gritz, and Graham W. Warren.
Obama Administration Proposes Raising Tobacco Tax
President Obama's proposed fiscal year 2014 budget would add a 94-cent increase to the federal tax on cigarettes and significant increases on other tobacco products as well. The proposed increase, if adopted, would bring the total federal cigarette tax close to $2 per pack. In 2007, President Bush's Cancer Panel cited a report recommending a $2.39 per pack tax.
Research has shown that smokers are price sensitive, and are more prone to try to quit as the prices of tobacco products rise. Indeed, studies indicate that every 10 percent increase in the price of cigarettes reduces youth smoking by 6.5 percent and overall cigarette consumption by about four percent, according to the American Cancer Society Cancer Action Network.