By Stephanie R. Land, PhD
Tobacco cessation assistance, imperative for tobacco users who seek medical care,1 takes on even greater urgency for individuals who are undergoing cancer screening or treatment. Cigarette smoking and other tobacco use in these settings raise important questions about how tobacco use affects patients and their cancer therapy, how to design cessation interventions for delivery with cancer screening and treatment, and how lung cancer screening affects tobacco use behavior at the individual and population level. For patients, quitting tobacco use can be the single most effective, cost-saving, toxicityfree means to prevent cancer or improve their outcomes after diagnosis.
Smoking Cessation Services in the Context of Lung Cancer Screening
The release of US Preventive Services Task Force recommendations for lung cancer screening with lowdose computed tomography (LDCT) and inclusion of LDCT screening in the US Medicare preventive benefits have led to a marked increase in the number of radiology clinics that deliver this service.2 NCI now plans to provide $18.4 million for a set of 6 5-year studies aimed at determining the key characteristics and implementation strategies of effective smoking cessation interventions designed for the LDCT setting. Smoking cessation treatment during LDCT screening offers great potential to reduce tobacco use rates and smoking-related morbidity and mortality.
Tobacco Use After Cancer Diagnosis
Cigarette smoking is prevalent among patients with lung and head and neck cancers, with rates as high as 40% to 60% at diagnosis. Studies comparing cancer patients who smoke cigarettes at the time of diagnosis to cancer patients who are former or neversmokers have demonstrated that current smokers have higher all-cause and cancer-specific mortality as well as higher risk of tobacco-related second primary cancer, and may also have higher risk of recurrence, poorer response to treatment, and increased toxicity.3 For patients in clinical trials, tobacco can be doubly damaging—affecting both response to experimental therapy and the ability of researchers to interpret trial results when interactions with tobacco use are not accounted for. A patient’s host factors, including tobacco use, are particularly important in the era of precision medicine.4 Tobacco use during and after cancer treatment should be recorded, and all patients should be offered cessation assistance.5
In a recent effort by NCI in collaboration with the American Association for Cancer Research (AACR), the NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified a priority research agenda regarding tobacco use after cancer diagnosis.
The Task Force also designed and tested the Cancer Patient Tobacco Use Questionnaire (C-TUQ), a key tool for initial and follow-up assessments in cancer clinical trials.6,7 The C-TUQ includes a “Core” short form of 4 smoking status and history items for routine use in cancer research, and an “Extension” to capture more detailed history, use of other tobacco products, cessation, and secondhand exposure. The Extension also includes smoking behavior during time periods specific to the cancer treatment trajectory, providing important data not available from general population questionnaires. The Task Force recommends that tobacco use be assessed at the patient’s entry to a clinical trial and at the end of cancer treatment, and if possible, during treatment (e.g., before and after cancer surgery and on day 1 of each chemotherapy cycle). Broad use of the C-TUQ will enable researchers to gather and pool data on tobacco use by cancer patients, which will advance the scientific agenda identified in the Task Force recommendations. In August 2016, NCI awarded supplemental funding to selected investigators in the National Cancer Trials Network and the NCI Community Oncology Research Program to facilitate implementation of C-TUQ assessments in their multi-center cancer trials.
As many as 50%–70% of patients who smoke at the time of diagnosis do quit, at least initially; however, many relapse during the course of treatment. The limited availability of evidence-based cessation treatment in the cancer care setting and low patient utilization of such treatment are barriers to improving and sustaining cessation rates. NCI currently funds research regarding how to effectively deliver smoking cessation interventions to cancer patients after diagnosis, and how cessation after diagnosis improves cancer outcomes.
Globally, cancer screening and treatment hold great promise as opportunities to provide tobacco cessation assistance and reduce the burden caused by tobacco use worldwide. ✦
1. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence. 2008 Update. Clinical practice guideline. 2008; http://www.ahrq.gov/path/tobacco.htm#Clinic. Accessed Sept 14, 2016.
2. Mulshine J, Hirsch F, Field J. Update on low-dose CT lung cancer screening implementation in the United States. IASLC Lung Cancer News 2016; https://www.iaslc.org/sites/default/files/ wysiwyg-assets/News/ilcn_v1n2_june2016_1.pdf. Accessed Sept 14, 2016.
3. US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General: United States Department of Health and Human Services. Public Health Service. Office of the Surgeon General;2014.
4. Ganz PA. Host factors, behaviors, and clinical trials: opportunities and challenges. J Clin Oncol. Aug 10 2012;30(23):2817-2819.
5. Morgan G, Schnoll RA, Alfano CM, et al. National Cancer Institute Conference on Treating Tobacco Dependence at Cancer Centers. J Oncol Pract. May 2011;7(3):178-182.
6. Land SR, Warren GW, Crafts JL, et al. Cognitive testing of tobacco use items for administration to patients with cancer and cancer survivors in clinical research. Cancer. Jun 1 2016;122(11):1728-1734.
7. Land SR, Toll BA, Moinpour CM, et al. Research Priorities, Measures, and Recommendations for Assessment of Tobacco Use in Clinical Cancer Research. Clinical cancer research : an official journal of the American Association