Smoking Cessation in the Oncology Setting...cigarette smoking and adverse health outcomes. Quitting...
Transcript of Smoking Cessation in the Oncology Setting...cigarette smoking and adverse health outcomes. Quitting...
Smoking Cessation in the Oncology Setting Scott Antle Suzanne Drodge Wednesday’s at Noon Lecture Series March 30, 2017
Objectives • Presentevidenceastotheclinicalandeconomicbenefitof
smokingcessa/ona9eracancerdiagnosis• Demonstratetheimpactofcon/nuedsmokinguponcancer
treatment• Highlightworkbeingplannedtointegratesmokingcessa/oninan
ambulatoryoncologyse?ng• Demonstratethesuppor/veroleofprimarycareprovidersin
smokingcessa/ona9eracancerdiagnosis
Overview • CancerCareProgram• TheTobaccoAddic/on• ImpactonCancerTreatment• BenefitsofSmokingCessa/onA9eraCancerDiagnosis
• Pharmacotherapy• TobaccoCessa/onandRelapsePreven/oninCancerCare
Cancer Care Program
• TheCancerCareProgramoperatesoutoftheDr.H.BlissMurphyCancerCentreinSt.John’s– RegionalCancerCentresinGander,GrandFalls-Windsorand
CornerBrook
• Chemotherapyprovidedin~20sitesacrossNL• 51siteswithtele-oncology• Approximately200healthcareproviders
– Oncologists,physicians,nursing,socialwork,medicalphysics,radia/ontherapy,nutri/on,clericalsupport,administra/on,cancerregistry,IT
2016 Canadian Cancer Statistics (NL)
Newcases:• Males:2,000• Females:1,900• Total:3,900(ASI:610.7/100,000)*Deaths:• Males:780• Females:670• Total:1,450(ASM:228.7/100,000)*
Tobacco & Cigarette Smoke
• Over 7000 constituents in cigarette smoke
• 60+ known carcinogens • ++ additives
– Enhance consumption – Increase flavor – Increase addiction
Tobacco: A Powerful Addiction
Cigarecesmokingproducesarapiddistribu/onofnico/netothebrain,withdruglevelspeakingwithin10secondsofinhala/on.Theacuteeffectsofnico/nedissipatewithinafewminutes,causingtheneedtocon/nuerepeatedintakethroughouttheday.
Tobacco & Cancer • Largestsinglecontributortocancerrisk• Smokingcontributesto30%ofallcancerdeaths• Smokingaccountsforapproximately85%oflung
cancerdeaths• Sufficientscien/ficevidencetolinktobaccocausallyto
15othercancers:– oralcavity,nasalcavityandparanasalsinuses,pharynx,larynx,
esophagus,stomach,liver,pancreas,cervix,ovary,kidney,ureter,bladder,bowel,acutemyeloidleukemia
• Somelimitedevidenceforalinkbetweentobaccosmokingandbreastcancer
2014 US Surgeon General’s Report
• Studies between 1990-2012 – About 400 studies with over 500,000 patients
• Evaluation of smoking effects on: 1.Overall mortality/survival 2.Cancer-specific mortality/survival 3.Response to treatment 4.Toxicity of treatment 5.Cancer recurrence 6.Risk of second primaries
2014 US Surgeon General’s Report Conclusions
– In cancer patients and survivors, the evidence is sufficient to infer a causal relationship between cigarette smoking and adverse health outcomes. Quitting smoking improves the prognosis of cancer patients.
– In cancer patients and survivors, the evidence is
sufficient to infer a causal relationship between cigarette smoking and increased all-cause mortality and cancer-specific mortality.
2014 US Surgeon General’s Report Conclusions
• Incancerpa/entsandsurvivors,theevidenceissufficienttoinferacausalrela0onshipbetweencigarecesmokingandincreasedriskforsecondprimarycancersknowntobecausedbycigarecesmoking,suchaslungcancer.
• Incancerpa/entsandsurvivors,theevidenceis
sugges%vebutnotsufficienttoinferacausalrela%onshipbetweencigarecesmokingandtheriskofrecurrence,poorerresponsetotreatment,andincreasedtreatment-relatedtoxicity.
Tobacco Cessation and Cancer Care
• Cigarecesmokeini/atestumorgrowthandmay
promotetumorprogression.• Stoppingtobaccouseisoneofthebestthingsa
pa/entcandotohelptheircancertreatment.• TheUSSurgeonGeneralindicatedthatbecoming
tobaccofreecanimproveoutcomesby~40%.
Tobacco Cessation and Cancer Care
• EvidencesupportsSmokingcessa/onbecomingastandardofcarewithinanycancertreatmentplan
• ItisarguedthatIfyouareabletotreatwith
chemotherapyand/orradiotherapyforthepurposeofextendingsurvivorshipthenweneedtoconsiderapa/entssmokinghistoryandoffersmokingcessa/on
Clinical Evidence
• “…theevidenceisclearthattobaccouseinpa/entswithcancerleadsto…”
• decreasedtreatmentefficacyandsafety• decreasedsurvival• decreasedqualityoflife• increasedtreatment-relatedtoxicity• increasedriskofcancerrecurrence• Increasedriskofsecondprimarytumours
Clinical Evidence
• “Datasuggestthattobaccocessa%oncanimproveoutcomesandsurvivalinpa%entswithcancer,yetfullexecu%onofevidence-basedcessa%oninterven%onsisinfrequentinoncologyse?ngs.”– Dr.GrahamWarren,TheParadigmShi9
Impact on Cancer Treatment • Thereareseveraltreatmentop/ons
• Surgery• SystemicTherapy• Radia/onTherapy• Pallia/veCare
• Con/nuedsmokinga9eracancerdiagnosisandduringac/vetreatmenthasasignificantimpactonoutcomesandtreatmentsideeffects
Tobacco use & treatment side effects
Chemotherapy Radiation Surgery • Exacerba/onofsideeffectsincluding:
• Immunesuppression• Weightloss• Fa/gue• Pulmonaryand
cardiactoxicity• Increasedincidence
ofinfec/on• Mayalterthemetabolismand/ormechanismofac/onofchemotherapymakingitlesseffec/ve
• Reducedtreatmentefficacy• Increasedtoxicityandsideeffectstoinclude:
• DryMouth(Xerostomia)
• Oralmucosi/s(mouthsores)
• Lossoftaste• Pneumoni/s• So9/ssueandbone
necrosis• Poorvoicequality
• Increasedcomplica/onsfromanesthesia• Pulmonarycomplica/ons• Poorwoundhealing• Increasedriskofinfec/on
Smoking and Chemotherapy
• Erlo%nib(e.g.NSCLCandPancreas)– Loweroverallresponseinsmokersvsneversmokers– Requiretwicethenormaldosetoproduceneededcircula/ng
levelsinsmokersversusnon-smokers• Sheppardetal.(July14,2005).NEJM353:123-132.
• Irinotecan(e.g.ColorectalcancerandSCLC)– smokershad~40%lowersystemicexposuretotheac/ve
metaboliteSN-38comparedtonon-smokers• VanderBoletal.(2007)JCO25:2719-2726.
Smoking and Molecular Therapy
• StudybyVincenzi(2009)demonstratedthatac/vesmokingisassociatedwithlessclinicalbenefit(responseplusstablediseasein54%versus88%)thannon-smokers
• Cetuximab(eg:colorectalandheadandneck)cigarece
smokingmayberesponsibleforadecreaseintheresponserateandleadtoalower/metoprogression(oftumor)fromcetuximab-basedtreatmentsforadvancedcolorectalcancerspa/entsamongsmokers.– Vincenzietal.(August2009).BiologicalTherapy,945-949.
Smoking & Radiation Therapy
• Smokerswhocon/nuetosmokeduringXRThaveasignificantlylowerrateofcompleteresponsetoradia0ontherapy(45%vs74%)and2-yearsurvival(39%vs66%)
• Recentquicersweremorelikelong-termquicersthanthosewhocon/nuedtosmokeintermsoftheirlikelihoodofsurvivingat18months
• BrowmanGPatal.NEJM1993– Dr.JinkaSathya,Radia%ononcologistattheDBMCCco-author
Smoking and Therapeutic Response
Warren,GMKeynotepresenta/on,January2017
CS=con/nuedsmokingRT=radia/ontherapy
Tobacco Cessation • Mosteffec/ve
– behavioraltherapies,non-prescrip/onandprescrip/onmedica/onsareusedincombina/on.
• Amul/disciplinaryapproachiscrucial• Tobaccocessa/onmodelsarebriefandgoaldirected
– 5A’s– 3A’s– 2A’s1R
• TobaccoCessa/on=ChangeManagement
Impact on Cancer Centers
• Smokingcessa/onisacosteffec/vemethodtodecreaserecurrenceriskandimprovetreatmentoutcomes
• Pa/entshavetheopportunitymaximizethebenefitoftheircancertreatmentwithsupportfromsmokingcessa/onclinics
• Avoiding2ndlinecancertherapyimprovesqualityoflifeandiscosteffec/ve
Smoking Cessation and Relapse Prevention
• Offerabestprac/cesmokingcessa/onandrelapsepreven/onprograminanambulatoryoncologyse?ng
• Supportavailabletocancerpa/entsreceivingac/vetreatment
• Pilotprogram– Head/neckandlungcancerpa/ents– Pa/entsofferedclinicalappointment,medica/on,and
behavioralsupport– Familymembersofferedbehavioralsupport
Key Deliverables to Planning a Cessation Program
• ProgramModelandAlgorithm• BestPrac/cereviewofotherprograms• Rela/onshipBuilding(PrimaryCareProviders)• Resourcedevelopment:
– Clinicalguidelines– Pa/entbrochure,guidebook– Educa/onalpresenta/ons– Communica/onsstrategy– Pharmacotherapybusinesscase– Educa/onalopportuni/es– Programcostes/mates– ProgramSustainabilityModel
Best Practice Smoking Cessation
• Ask• Advise• Referral
Screen
• Clinicalappointment• Pharmacotherapy• BehavioralThearpy
Counsel
• ClinicalfollowupAppointment
• AdjustPharmacotherapy• PCPSupport
Follow-up
Pharmacotherapy Considerations in Oncology
NRT• Mayirritateoralmucosa• Withheadandneckcancersmayexacerbatecondi/on• Contraindicatedforpre-opera/vesurgery
Varenicline(Champix)• Dosageconsidera/onsforpa/entsexperiencingnausea• Noevidenceonsafety/efficacy• Besttousewithbehavioralcounselling
Bupropion(Zyban)• Mayreduceappe/te• Concurrentuseoftamoxifenorprocarbazineiscontraindicated• Anxietymayincrease
Combina/onNRTandmedica/ons• Theaddi/onofnico/nepatchtoVareniclinedidnotcausesignificantchangesinsideeffectprofiles• Sideeffectsofcombina/ontherapyofthepatchandBupropionwerenotsignificantlydifferentversusbupropionalone
PharmacotherapyOp%ons
Pa%entscreened
ComboNRTNico/nePatch+Shortac/ngNRT(gum,inhaler,
lozenge)
Varenicline+NRT
Bupropion(Zyban)+NRT
Varenicline(Champix)
Bupropion
1st4weeksWeeks5-12Ifpreviousnotworking
AdoptedfromPharmacotherapyOp/onsfromtheCentreforAddic/onsandMentalHealth(CAMH)
Role of Primary Care Provider
• Priortoconsulta/onatthecancerprogramaskingandadvisingpa/entstoquitsmokinggivesthemaheadstartfortheircancertreatmentplan
• PrimaryCareProvidersplayacri/calroleinacancerpa/entstransi/onintosurvivorship
• Communica/onbetweenthecancerprogramandthePrimaryCareProviderisimportanttoensureposttreatmentpreventa/vecare
Role of Primary Care Provider
• Althoughacutelyawareofthedangersofsmokingandtobaccouse,Primarycareprovidersmustbecomechampionsofposttreatmentcessa/on
• Encouragepa/entstocon/nuetobesmokefree• PrimaryCareProviderswillbeno/fiedthatpa/entshave
receivedcessa/onsupportatthecancerprogram.• Con/nuetoaskaboutsmokingstatus• Assistinaccessingaddi/onalcessa/onsupportspost
cancertreatment
References • AmericanSocietyofClinicalOncology(ASCO).(2012).TobaccoCessa/onGuideforOncologyProviders.
AmericanSocietyforClinicalOncology.• BrowmanGPI,W.G.(January21,1993).InfluenceofCigareceSmokingontheEfficacyofRadiotherapyinHead
andNeckCancer.NewEnglandJournalofMedicine,328(3):159-163.• CanadianCancerSociety.(2016).CanadianCancerSociety'sAdvisoryCommiceeonCancerSta/s/cs.Canadian
CancerSta/s/cs2015.Toronto.• CenterforAddic/onandMentalHealth(camh).(2016).CAMHcenterforaddic/onsandmentalhealth.
Retrievedfromwww.nico/nedependenceclinic.com• SheppardMD,F.A.(July14,2005).Erlo/nibinPreviouslyTreatedNon-SmallCellLungCancer.NewEngland
JournalofMedicine,353:123-132.• Stahl,S.M.(2008).Stahl'sEssen/alPsychopharmacology3rdEdi/on.Neuroscien/ficBasisandPrac/cal
Applica/ons.NewYork,NYUSA:CambridgeUniversityPress.• USDHHS,U.S.(2014).TheHealthConsequencesofSmoking-50yearsofProgress.AreportoftheSurgeon
General.Atlanta,GA,USA:U.S.DepartmentofHealthandHumanServices,CentresforDiseaseControlandPreven/on,Na/onalCenterforChronicDiseasePreven/onandHealthPromo/on,OfficeofSmokingandHealth.
• VanderBolJM,M.R.(2007).CigareceSmokingandIrinotecanTreatment:Pharmacokine/cInterac/onandEffectsonNeutropenia.JournalofClinicalOncology,25:2719-2726.
• VincenziB1,S.D.(August2009).Cigarecessmokinghabitmayreducebenefitfromcetuximab-basedtreatmentinadvancedcolorectalcancerpa/ents.BiologicalTherapy,945-949.
• Warren,G.(2017).SmokingandtheCancerPa/ent:ClinicalBehavioralandAdministra/veConsidera/ons.CanadianPartnershipAgainstCancer,SmokingCessa/oninCancerCaremee/ng,(pp.1-55).Ocawa.