Smoking Cessation in the Oncology Setting Scott Antle Suzanne Drodge Wednesday’s at Noon Lecture Series March 30, 2017
Disclosures
• Therearenofinancialoreduca/onaldisclosures
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 & Cigarette Smoke
Tobacco: A Powerful Addiction
Cigarecesmokingproducesarapiddistribu/onofnico/netothebrain,withdruglevelspeakingwithin10secondsofinhala/on.Theacuteeffectsofnico/nedissipatewithinafewminutes,causingtheneedtocon/nuerepeatedintakethroughouttheday.
The Addiction: Molecular and Behavioral
Tobacco: A Powerful Addiction
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& Cancer Care
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
Impact on Cancer Centers
Warren,GMKeynotepresenta/on,January2017
Impact on Cancer Centers
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)
Mo/va/onInterviewing:ChangeManagement
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.
Questions
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