Tobacco Use Often Falls Through the Cracks in Oncology Practices

Some people are so addicted to tobacco that a diagnosis of cancer is not enough to make them quit smoking. Patients with cancer who continue to smoke increase their chances of compromising the effects of treatment, of having worse adverse effects from treatment, and of developing a second cancer or clinically evident cardiovascular disease.

Despite this problem, many cancer centers and oncology practices have not devoted resources to addressing tobacco use. To bridge the gap between the need for tobacco use intervention and services delivered, a panel of the American Association for Cancer Research (AACR) issued a policy statement, Assessing Tobacco Use by Cancer Patients and Facilitating Cessation, during the organization’s annual meeting.

Nurse practitioners and physician assistants are in an excellent position to provide assessment of tobacco use and evidence-based interventions. The AACR hopes that the new policy statement will be a wake-up call for oncology practices to address this significant issue.

The back story is that recent surveys and studies showed that a sizable proportion of oncology practices do not routinely address tobacco use and that tobacco use is not documented at baseline and follow-up in many clinical trials, even though it is a confounding factor for treatment.

In a survey of National Cancer Institute (NCI)–designated cancer centers, only 38% of those responding documented smoking status as a vital sign, and less than 50% of these centers had dedicated personnel for tobacco cessation. By contrast, 78% of the same centers have dedicated nutrition personnel.

A separate survey revealed that while 90% of oncologists who responded believed that tobacco use affects cancer outcomes and that tobacco cessation should be included as standard of care, only 40% of these oncologists provided routine assistance for smoking cessation. Moreover, less than 10% of oncologists had specific training in smoking cessation while only 33% of lung cancer specialists considered themselves adequately trained in smoking cessation.

Recently, a review of 155 NCI Cooperative Group studies revealed that only 29% of registered trials assessed tobacco use at enrollment. Less than 5% of these trials included follow-up on subsequent tobacco use status.

Smoking is among the most difficult addictions to treat. Studies suggest that although about 50% of smokers try to quit, only about 4% to 7% are successful in doing so without evidence-based intervention.

Tobacco use is the major risk factor for lung cancer, but it is also implicated in 18 other types of cancer. “A frequent assumption is that once cancer develops, it is fruitless to stop smoking. This is not true!” said Roy Herbst, MD, chair of the panel that produced the AACR policy statement and chief of medical oncology at Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut.

Evidence-based approaches to tobacco use cessation include pharmacotherapy and nicotine chewing gum, as well as the 5A approach to smoking cessation: ask about smoking status, advise people to quit, assess interest in quitting, assist with pharmacotherapy and counseling, and arrange follow-up. However, many healthcare providers do not utilize these approaches.

Concrete Steps

AACR’s policy statement endorses a number of recommendations to remedy this treatment gap, making oncology practices responsible for providing assessment and intervention for patients who continue to smoke and recent quitters.

The following points are included in the recommendations:

• Repeated documentation of tobacco use in all patients with cancer, so that the confounding effects of smoking on treatment, disease progression, and comorbidities can be tracked in clinical trials, starting at registration and continuing through follow-up
• Tobacco use should also be documented in all clinical care settings. Universal standardized measurement of tobacco use and exposure is required to be able to make cross-center comparisons and compile a meaningful database
• Researchers and healthcare quality and accreditation bodies should incorporate evidence-based criteria
• Healthcare systems, payers, and funding bodies should provide reimbursement for tobacco use interventions along with incentives for developing and delivering them

The Affordable Care Act (ACA), which will be in effect in 2014, provides for reimbursement for smoking cessation interventions by insurance plans, but this will vary by state and be evidence based. In some states, tobacco use interventions are reimbursable if offered by nurse practitioners and physician assistants. Electronic medical records, also part of the ACA, will track smoking status. l

Reference
Herbst RS. Reducing tobacco-related cancers incidence and mortality. Presented at: American Association for Cancer Research 2013 Annual Meeting; April 9, 2013; Washington, DC.