Smoking Cessation Prior to Lung Cancer Surgery

By Jessica Donington, MD, MSCR
Posted: November 12, 2019

Dr. Jessica Donington

Approximately 80% to 85% of patients undergoing lung cancer resections have a smoking history, and 20% are active smokers. Never smokers have improved short- and long-term outcomes following lung resection compared to those who have smoked. Th e value of smoking cessation prior to or at the time of lung cancer diagnosis is significant.1

The recent National Lung Screening Trial provided a unique cohort to study the effects of active tobacco use on early-stage lung cancer survival. The trial was limited to individuals with more than a 30 pack-year smoking history and included 24,190 current smoker and 26,073 former smokers. Lung cancer–specific mortality was higher in current compared to former smokers (HR 1.69) and lowest in those with the greatest number of years without smoking. Each additional year of smoking cessation resulted in a 6% decrease risk for lung cancer death.2

Depending on the definitions used and the extent of resection, the risk of complication following lung cancer surgery ranges from 6% to 50%. Many risk factors for operative morbidity are not modifiable including age, sex, and cancer stage, but smoking is a modifiable risk. Smoking is associated with increased hospital death and complications following lung cancer resections. The risk for respiratory complications is two times higher for active smokers compared to never smokers.

Defining Benefit
Smoking cessation improves pulmonary function over time. There is some uncertainty as to whether operative risk related to smoking can be mitigated in the timeframe needed to initiate therapy for a newly diagnosed cancer. Whereas enhancements in spirometry, ciliary clearance, and immune function occur over months and years, sputum production decreases in the initial weeks after resection. There is a similar time-related decrease in risk for postoperative respiratory complications. A recent meta-analysis of 25 trials noted a 23% reduction in postoperative respiratory complications with just 4 weeks of smoking cessation and a 47% decrease with more than 8 weeks of cessation.3 Evidence for decreased operative complications after less than 4 weeks of smoking cessation is less clear, but there is also little evidence supporting the concept that short-term abstinence leads to acute withdrawal, with increased sympathetic activity and cardiovascular complications. The lack of significant perioperative benefit to smoking cessation within 4 weeks of surgery should not deter clinicians from strongly encouraging thoracic surgery patients to stop smoking. There are significant long-term benefits to cessation, and the perioperative period is an incredibly “teachable moment.”

There are important long-term oncologic benefits to smoking cessation at the time of lung cancer diagnosis. The carcinogens in tobacco act as both a genetic inducer of malignancy and a promoter of tumor progression. Those with early-stage lung cancer who continue to smoke have a higher risk of recurrence, second primaries, and all-cause mortality compared to those who stop smoking at diagnosis.4 Life table modeling suggests that most of the mortality benefit is due to cancer progression rather than cardiovascular causes.

Smoking cessation at any time is meaningful for all patients, but especially for those diagnosed with lung cancer. In patients with early-stage disease, smoking cessation improves short- and long-term outcomes. Tobacco cessation programs are an essential component of any lung cancer treatment team. ✦

About the Author: Dr. Donington is a professor and chief of Thoracic Surgery, University of Chicago Medicine and Biologic Sciences.

References:
1. Fukui M, Suzuki K, Matsunaga T, Oh S, Takamochi K. The Importance of Smoking Cessation on Surgical Outcome in Primary Lung Cancer. Ann Thorac Surg. 2019;107(4):1005-1009.

2. Tanner NT, Kanodra NM, Gebregziabher M, et al. The Association between Smoking Abstinence and Mortality in the National Lung Screening Trial. Am J Respir Crit Care Med. 2016;193(5):534-541.

3. Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012;59(3):268-279.

4. Parsons A, Daley A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ. 2010;340:b5569.