Lung Cancer and Smoking Cessation

gdpawel

"Since a substantial number of patients presenting with lung cancer either smoked in the recent past or continue to do so, it is important to make sure that the patient stops smoking as soon as possible to improve their treatment outcome," says Dr. Carolyn M. Dresler, Head, Tobacco and Cancer Group of the International Agency for Research on Cancer. She added, "the emphasis should be on improvement of treatment outcome and future health improvement."

There are guidelines regarding smoking cessation techniques that have resulted from reviews of the world's literature and are very well accepted throughout the medical and psychological fields. However, "the biggest problem remains in having healthcare providers implement them routinely," Dr. Dresler says, "Most have emphasized the role of the primary healthcare provider in providing smoking cessaton advice to patients, whereas the specialists, such as medical oncologists, radiation oncologists, thoracic surgeons or pulmonary care specialists should be dealing with the health problems resulting from the smoking as the patient faces imminent interventions such as radiation therapy, chemotherapy or surgery."

She makes the point that since ongoing smoking may significantly affect the outcome of subsequent surgery or therapy and negatively impact long-term survival, it is now the specialists' turn to provide the urgent smoking cessation treatment. With the advent of medicare changes under the new Medicare Modernization Act (MMA), the specialists will be reimbursed for providing evaluation and management services, making referrels for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival, I certainly hope they add smoking cessation guidance and support.

www.treatobacco.net is an evidence-based site containing information in 11 languages on tobacco dependence treatment relative to efficacy, safety, demographics and health effects, health economics, and policy.

www.cdc.gov/tobacco/ is a site to let you know everything you wanted to know about tobacco at the CDC.

www.guideline.gov/summary/summary.aspx?doc_id=2958&nbr=2184 is the National Guideline Clearinghouse web site for smoking cessaton.

gdpawel

Smoking, The Missing Drug Interaction in Clinical Trials: Ignoring the Obvious

Ellen R. Gritz,1 Carolyn Dresler,2 and Linda Sarna3
Department of Behavioral Science, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; 2Tobacco and Cancer Group, IARC, Lyon, France; and 3School of Nursing, University of California-Los Angeles, Los Angeles, California

Abstract

Tobacco use is universally recognized as the foremost preventable cause of cancer in the United States and globally and is responsible for 30% of all cancer-related deaths in the United States. Tobacco use, including exposure to secondhand smoke has been implicated as a
causal or contributory agent in an ever-expanding list of cancers, including lung, oral cavity and pharynx, pancreas, liver, kidney, ureter, urinary bladder, uterine cervix, and myeloid leukemia. In addition to and independent of the etiologic effects of tobacco carcinogens in numerous cancers, there is a growing literature on the direct and indirect effects of smoking on treatment efficacy (short-term and long-term outcomes), toxicity and morbidity, quality of life (QOL), recurrence, second primary tumors (SPT), and survival time.

Oncology health professionals have called for increased advocacy for tobacco control. Despite the critical relevance of smoking to cancer
outcomes, most oncology clinical trials do not collect data on smoking history and status unless the malignancy is widely acknowledged as smoking related (e.g., lung or head and neck cancer). Usually, these data are collected only at trial registration. Changes in smoking status during treatment or follow-up are monitored in very few trials and are infrequently reported in sample descriptions or included in analysis plans as a potential moderator of outcomes. Based on mounting evidence that tobacco use affects cancer treatment outcomes and survival, we recommend that smoking history and status be systematically collected as core data in all oncology clinical trials: at diagnosis, at trial registration, and throughout treatment and follow-up to long-term survival or death. We feel that the inclusion and analysis of such data in clinical trials will add important information to the interpretation of outcomes and the development of scientific knowledge in this area.

Smoking status has been called another ‘‘vital sign’’ because of its relevance to a patient’s immediate medical condition. We explain the critical value of knowing the smoking status of every patient with cancer at every visit by providing a brief overview of the following research findings: (a) the effects of tobacco use on cancer treatment and outcome; (b) recent findings on the role of nicotine in malignant processes; (c) some unexpected results concerning tobacco status, treatment, and disease outcome; and (d) identifying key questions that remain to be addressed. We provide a suggested set of items for inclusion in clinical trial data sets that also are useful in clinical practice

(Cancer Epidemiol Biomarkers Prev 2005;14(10):2287–93)

Conclusions

We can no longer ignore the obvious: smoking is a critical variable that affects cancer treatment and outcome and has been shown to vitiate or interact with the effects of some therapeutic agents and chemopreventive agents. Measurement of smoking history and status in clinical trials of cancer therapy will increase our knowledge of the adverse effects of the constituents of tobacco smoke, including nicotine, and of drug interactions.

Oncology health professionals have called for increased advocacy for tobacco control. Furthermore, the routine inclusion of smoking status and cessation need to become a standard of care for all patients. The inclusion of smoking data in oncology clinical trials will also provide clinicians with improved means of delivering individualized advice to patients with cancer that may be critical in motivating their cessation efforts and sustained abstinence.

Scientific, financial, and clinical support is critical to this goal. The failure to date to assess, analyze, and report smoking status has limited our ability to investigate the effect of smoking on treatment efficacy and outcome. The time has come to integrate data about the single most important lifestyle risk factor in cancer prevention into cancer treatment and survivorship trials.

gdpawel

No "pharmaceutical" trial ever followed whether patients smoked during their clinical trials, despite dosing themselves daily with cigarettes with 4000 chemicals in them. The addition of nicotine inhibits the ability of a chemo drug (like etoposide) to induce apoptosis by 61%. If a drug like nicotine, which occurs in the highest concentration of any drug in a cigarette, inhibits the ability of a major chemotherapy drug by 61%, a medical oncologist should care if it was being ingested during treatment.

The vast majority of clinical trails performed are ones that test one chemotherapeutic regimen against another. Single arm clinical trials provide the tumor response evidence that is the basis for approving new cancer drugs. The randomized, controlled clinical trial may likely remain the standard for evidence of clinical decision-making in cancer medicine, however, observational methods and systematic reviews are clearly useful. Even with the importance of clinical trials, it is crucial to work on reducing their inherent limitations, including uncertain generalizations, and to expand the use of the randomized clinical trial paradigm to areas beyond proving biological activity, like diagnostic testing.

Evidence based medicine, since the 1970's, depended upon the randomized, controlled trial. It rests upon the assumption that evidence should be determined and applied as a basis for medical decision-making. Evidence is based upon quantities, similarities, populations, and averages, rather than qualities, idiosyncracies, individualization, and specifics. It would be surprising if the most ardent supporter of evidence based medicine would ever advocate a randomized trial for an intervention in which an observational study showed remarkable efficacy in preventing a near death situation. Many major medical advances have never been subjected to a prospective randomized study before being introduced into routine management because their beneficial effects have been obvious.

Recognizing the reliability of the evidence upon which clinical practice has increasingly come to depend, the time has come for physicians to reassess the value of direct observation, and to trust more readily both the empirical and intuitive discoveries they make each day in their personal experience, even if those discoveries are contradicted by the best available evidence. There could be nothing more serious than the call for physicians to reconsider what it means to be authentic and true.

crot1998

Not sure why you are posting all of this on the lung cancer forum as this is more of a support group.

gdpawel

crot1998 said:

Not sure why you are posting all of this on the lung cancer forum as this is more of a support group.

It's about lung cancer and smoking cessation. Since a substantial number of patients presenting with lung cancer either smoked in the recent past or continue to do so, it is important to make sure that the patient stops smoking as soon as possible to improve their treatment outcome. Dr. Dresler and her colleagues are hightening the awareness that it is the specialists (oncologists) turn to provide the urgent smoking cessation treatment. With these specialists beginning to receive the added reimbursement to provide evaluation and management services provided by the new MMA bill, smoking cessation guidance and support is urgently needed. What more support is that?

Plymouthean

crot1998 said:

Not sure why you are posting all of this on the lung cancer forum as this is more of a support group.

I agree with you. Althought this is important information, I think it can be a tough read for someone undergoing chemo and/or radiation treatments. The relevant part of the postings here seems to be that the use of tobacco interferes with chemotherapy. That's good for us know. To an exhausted, nauseous, fatigued, sometimes confused and depressed patient, undergoing treatment, a brief, to-the-point paragraph is plenty. The information about doctors doing studies, or the lack thereof, should be addressed to doctors in another forum.

Plymouthean

Plymouthean said:

I agree with you. Althought this is important information, I think it can be a tough read for someone undergoing chemo and/or radiation treatments. The relevant part of the postings here seems to be that the use of tobacco interferes with chemotherapy. That's good for us know. To an exhausted, nauseous, fatigued, sometimes confused and depressed patient, undergoing treatment, a brief, to-the-point paragraph is plenty. The information about doctors doing studies, or the lack thereof, should be addressed to doctors in another forum.

Re: my last post; My agreement is with crot1998

crot1998

Plymouthean said:

Re: my last post; My agreement is with crot1998

Thanks Ernie, I thought this was a bit much for what I consider to be more of a support site for patients/caregivers.

gdpawel

That's okay. There are some very bright people on this board who would like to be informed about the ins and outs of cancer medicine, to know what they're up against in fighting the disease for themselves or for a loved-one. Having as much information helps greatly. It is all part of informed consent.

Plymouthean

gdpawel said:

That's okay. There are some very bright people on this board who would like to be informed about the ins and outs of cancer medicine, to know what they're up against in fighting the disease for themselves or for a loved-one. Having as much information helps greatly. It is all part of informed consent.

I'm not saying your input isn't valuable. I believe that it should be posted under resources. Thanks for the little dig about "bright people". Totally uncalled for. Nobody questioned your "wattage".

crot1998

Plymouthean said:

I'm not saying your input isn't valuable. I believe that it should be posted under resources. Thanks for the little dig about "bright people". Totally uncalled for. Nobody questioned your "wattage".

I agree with you Ernie. I consider myself to be a bright person and a successful medical professional. I just thought that perhaps a summary and a reference would have been sufficient, no other point needs to be made and I think we can end this discussion thread at that.

gdpawel

This information would have no applicability in the resource section, and would be totally lost to all those who think differently and need support with pertinent information. Why plymouthean and crot1998 have all the hang-ups is beyond reason.