Cancer Treatment and

Care Innovations

Ingrid Plueckhahn RN MPH

Advanced Practice Nurse

Smoking Cessation Support

Innovation

• Identifying unmet needs

• Exploring how to address needs

• Using EBP to support processes

• Differing in approach

• Has an impact on patient outcome

Early Strategies

• Lung Cancer inpatient unit: • Requesting support to quit smoking

• No clinical expertise to assist

• Liaised with Quit Victoria

– Proposal for Educating Nurses in EB

– Smoking Cessation Strategies

• Patients offered• Brief inpatient intervention

• Referred to Quit Line

Evaluation

• “Quit Support” nurses

– Person dependant

– Variance of structured support

– Ambivalence amongst staff

– Quit referrals inconsistent

– More work to do!

CRF: UoM / PMCC

• Does continued smoking when a patient has a cancer diagnosis have an impact on their cancer outcome

• Literature Review

• Cancer patients – Neglected population in smoking cessation

– Suffered adverse health consequences from smoking

– Survivorship

Benefits of Quitting with a

Cancer Diagnosis(Literature Review conducted through a Clinical Research Fellowship – Uni Melb):

• Decreased treatment complications

• Improved rates of complete response

• Less tumour resistance to cancer treatment

• Improved survival and relapse free survival

• Reduced rates of metastases

• Decreased second primary tumour rate

• Less aggravated weight loss

• Improved surgical outcomes

• Improved pain control

• Reduced infection rates

• Increased opportunities to continue anti cancer treatments

Opportunity to quit

• Cancer diagnosis is an

opportunity for behavioural

change: “teachable moment”

• Patients are willing to modify

behaviour and are Motivated

• Disease site, stage, & smoking

history predict quitting

Identified stakeholders

• Executive support and ratification

• Quit “Champions”

• Defined and included broad stakeholders for endorsement

Smoking cessation support

• What motivates?

• Routine clinical care then refer

• Quit support Champions

• Nurse led smoking cessation support clinic

• Free Pharmacologic support

• Review of “smoking areas”

Smoking Cessation Strategy

• Inform Peter Mac community of the harmful effects of tobacco smoke

• Highlight the benefits of quitting

• Denormalise the use of tobacco

• Research a smoking cessation program in an acute cancer centre

• Protect from exposure to tobacco smoke

• Provide incentives to quit

• Totally Smoke Free Hospital

Strategy for Support

• Resourced a Nurse Co-ordinator

as project manager (.4 EFT)

• Annual Budget

• Policy development for Totally

Smoke Free hospital

• Guidelines for Pharmacologic

support – patients and staff

Staff & Med Record Survey

• 39% response rate

• 97% rated SCS as important

• 69% aware of benefits of quitting

• 53% made comments about

– Stopping smoking at entrances

– Need to make PMCC totally smoke free

• 7% were current smokers

• Review of Med Records (100) 35% - 100%

Pilot study

n=40

• Acceptability / Appropriateness and Feasibility of smoking Cessation Program for patients with a cancer diagnosis:– Patients found program acceptable

– Expected support

– Increased motivation and confidence quit

– Requested more than one session (20%)

– All made reduction in cpd with 35% quit (at 6 months)

– Quit line referrals unsuccessful

Progress

• Brochure development

• Quitting medications available

• Support for staff

• Nurse Led Smoking Cessation

Support Clinic attracted VACCs

funding

Designated Smoking Area

• Controversial! (Expensive)

• Exclusive – inpatients only

• Discouraged smoking elsewhere

• Safe environment staff and patients

• Minimise fire risk

• Minimise ETS

• Closed within a year!

Policy re- write

• Smoke Free hospital

• Smokers to leave hospital precinct

• Patients accept responsibility

– Not accompanied by staff

• Staff discouraged to smoke with or in front of patients

• Staff de identified

• Voluntary

Policy Maintenance

• Orientation

• Staff encouraged to quit

• Cessation Counselling and support

• Clear delineation of boundaries

• Patients who smoke on property are approached and informed of policy

• All staff are responsible to enact policy

• Melbourne City council engagement

Education strategy

• “Champions” educated at Quit Vic

• Forums / presentations

• all clinical streams / multidisciplinary

• non clinical groups

• Grand round presentations

• GP and wider clinical community

presentations

• Patient / Community Advisory

Committee

Prospective StudyPrimary: To determine abstinence rate at 12

months

Secondary:

• Abstinence rate at 1, 3 & 6 months

• Point-prevalence abstinence rates at 1, 3, 6

and 12 months

• To compare the changes in QoL and distress

scores

• To determine the associations between patient/

treatment factors and prolonged abstinence (Mileshkin, Plueckhahn, et al.2009)

Results• n= 77 patients enrolled over 2 years

• Median age = 56 years (range 27 – 71), 61%

male

• 41 (58%) had a smoking-related cancer

• 24 (34%) were living with another smoker

• Mean age to start smoking = 16 (range 7-25)

• 25 (35%) heavy nicotine dependence

(Fagerstrom)

• 16 (23%) had reduced smoking

• 47 (66%) were planning to quit in the next

month

QUIT ratesTime-point Prolonged

abstinence rate

95% confidence

interval

1 month 53% (41 – 65%)

3 months 34% (23 – 47%)

6 months 28% (17 – 40%)

12 months 24% (14 – 36%)

Associations with successful

quitting

• Active plan to quit at baseline 49%

quit (p= 0.012)

• Hospital admission for treatment

toxicity 45% quit(p = 0.024)

• Having a smoking-related cancer

(33% vs 13% quit) p = 0.08

• No association with• nicotine dependence

• distress or global QOL

• use of pharmacotherapy

• efficacy of anti-cancer treatment

2007: Totally Smoke Free PMCC

• World Cancer Day (Feb 4) announced

• Totally Smoke Free on WNTD (May 31)

• Leadership in Cancer Prevention

• Statement about smoking & public health

• Policy review

• Reiterated voluntary compliance

• Senior Clinician engagement

Communication Strategies

• Key dates such as WNTD

• Brochure development

• Posters

• Web page alerts

• Grand Rounds

• Media releases

• Email signatures

2009: “Ask” at registration

• Systematic collection of data

• All patients are asked smoking status

• Information transferred to “Verdi”

• Flag for clinicians • to advise patients to quit

• refer for smoking cessation support

• Provides data for research

2011: Pharmacy led study

• Examined • Retrospective single arm

• n= 312

• Pack years

• Quit rates

• Findings• 50% ever smoked / 12% current

• Ave pack years: 27.8

• Low clinic recruitment: (7.3%)

• 25% patients quit at 12 months, PP = 33% quit

• 66% (reduction or cessation)

• 43% seen in SCC had not disclosed(Plueckhahn, Alexander, et al, 2011)

2010: Superannuation funds

• Challenged for tobacco investments

• Met with CEO’s

• Business case

• Conflicts of interest

• Tobacco free folios

• Future fund: tobacco will be dumped (>$250million worth of stocks)

• Continued pressure SF CEO’s • (Dr. Bronwyn King)

VNSH membership

– Information sharing

– Compliance

– Smoking cessation strategies

– Education

– Engagement

Future…

• VNSH standards

• Repeat staff survey

• Pre admission clinic study

• VCCC plans (RMH / RWH)

• Automated referrals from

registration

• Indigenous community / VACCHO

Success factors

• Strong executive support

• Patient focused

• Senior clinician engagement

• Research practice

• Maintain high profile

• Education

• Communication

Finally

• Smoking cessation ABCD

• ASK

• Briefly advise

• Cessation treatment patient

focus

• Document