Download Addressing tobacco use in patient with cancer

“Should I quit smoking?”
Impact of smoking
on cancer treatment
Berit Hofset Larsen and Kjersti Stokke
Department of Oncology – Oslo University Hospital (OUS)
The working group
• Berit Hofset Larsen;
Oncology nurse specialist
• Annette Bernt;
Oncology nurse specialist
• Kjersti Stokke;
Oncology nurse specialist / Mcs,
in charge of professional development
Oslo University Hospital (OUS), Department of Oncology
Additional resources
• Chief Physician Serena Tonstad,
Department of Endocrinology, OUS
• Chief Physician Gustav Lehne,
Department of Oncology, OUS
• Chief Physician Harald Holte Jr,
Department of Oncology, OUS
• Chief Physician Fridtjov Riddervold,
Department of Anesthesiology, OUS
• Gunhild Strickert Furuhaug;
Prescribing Pharmacist, Oslo Hospital Pharmacy
Questions from the nursing staff
Do smokers have less effect of cancer treatment?
Higher risk of side effects? What kind?
Higher risk of complications? What kind?
Increased mortality/morbidity among smokers
compared with non-smokers?
Do smokers have prolonged hospital stays?
Higher risk of recurrence?
What is the effect of quitting smoking?
What smoking cessation measures are effective?
How long in advance should patients stop smoking?
What kind of advice should we provide to our patients?
PICO
P : Chemotherapy, radiation therapy
I : Smoking, nicotine, tobacco, cigarettes
C : Quit smoking
O : Side effects, complications, mortality,
morbidity, treatment efficacy, relapse,
secondary cancer, hospital days
Search terms
P : *Smoking/ *Tobacco/ *Nicotine/ *"Tobacco Use Disorder"/
(smok* or nonsmok* or non-smok* or cigaret* or tobacco* or nicot*).ti.
I : (radiother* or brachyther* or radioimmunother* or chemother* or
chemo-radiat* or chemoradiat* or cytostat* or cytotox* or
chemoradiother* or chemoimmunother*).ti. ((irradiat* or radio* or
radiat*) adj (treatment* or therap*)).ti. *Cytostatic Agents/ or exp
*Neoplasms/dt or (*antineoplastic agents/ or exp *antibiotics,
antineoplastic/ or exp *anticarcinogenic agents/ or exp
*antimetabolites,antineoplastic/ or exp *antimitotic agents/ or exp
*antineoplastic agents, alkylating/ or exp *antineoplastic agents,
hormonal/ or exp *antineoplastic agents, phytogenic/ or exp
*myeloablative agonists/) or *Chemotherapy, Adjuvant/ or
*Antineoplastic Combined Chemotherapy Protocols/ or (*radiotherapy/
or *brachytherapy/ or *radioimmunotherapy/ or *radiotherapy,
adjuvant/ or *radiotherapy,computer-assisted/ or *radiotherapy
dosage/ or *radiotherapy, high-energy/)
Guidelines and databases
National Guidelines from Directorate of Health (Helsedirektoratet)
Guidelines International Network (G-I-N)
National Institute for Health and Clinical Excellence (UK)
Danish Centre of Clinical Guidelines
The Health Care Manual (Vardhandboken) – Sweden
Joanna Briggs (Aus)
(Best Practice Information Sheets, Evidence Recommendations, Systematic Reviews)
UptoDate
Best Practice
Clinical Evidence
The Cochrane Library
MacPlus Search from McMaster
Medline
Systematic search of the literature
By librarian specialist Gunn Kleven
January - May 2012
A few non-specific guidelines on
smoking cessation
Numerous single studies Critical
Review of the Literature
Request to Relis
(Pharmaceutical Information Center)
Search December 2012:
New Guideline from ASCO
New search autumn 2014
confirms and elaborate previous
findings
Findings
Several studies support the
conclusion that patients who
continue to smoke have
poorer effect of the cancer
treatment compared with
those who quit - whether the
cancer diagnosis is related
to smoking or not.
Continued tobacco use is
also associated with a
higher degree of toxicity.
(ASCO 2012)
The adverse effects of smoking are not limited
to cancer diagnoses associated with tobacco,
such as lung cancer or head/neck cancer
(Warren 2013)
Continued smoking is associated with a
higher mortality risk for several groups:
Breast cancer (Hooning et al 2007, Li et al 2009)
Prostate cancer (Kenfield et al 2011, Joshu 2011)
Colorectal cancer (Phipps et al 2011)
Esophageal cancer (Kountourakis et al 2011)
Cervical cancer (Waggoner et al 2006)
Ovarian cancer (Schlumbrecht et al 2011)
Leukemia (BMT) (Ehlers et al 2011)
Lymphoma (Talamini et al 2008)
Continued smoking increases the risk of ...
Reduced effect of cancer therapy
Postoperative complications and
prolonged recovery
Cardiovascular and respiratory
complications
Recurrence of cancer
Secondary malignancies
Poorer prognosis
Surgical treatment
Serious lung complications and
complications during anesthesia
Decreased wound healing
Increased likelihood of SSIs
(surgical site infections)
(ASCO , Nakagawa et al 2001,Liu et al 2011, Gajdos 2012)
I is disputed whether quitting shortly before an operation might increase
lung complications. Important to remove the tube quickly after surgery
Surgical treatment
Meta Analysis n= 7616:
Smokers had a higher risk of
tissue necrosis, ischemia and
impairments in wound healing
(Krueger & Rohrich 2001)
Radiation therapy
Lower response rates among active smokers compared
with former smokers and those who had quit before
starting treatment
(ASCO 2012, Bowman et al 2002)
Increased toxicity and side effects; oral mucositis, taste
alteration, dry mouth, weight loss, fatigue, pneumonia,
bone and tissue necrosis and poor voice quality
(ASCO 2012, Gritz et al 2008, Alsadius et al 2011, Chen et al 2011,
Eilef et al 2002, Wuketich 2012)
Radiation therapy
A study of patients with ENT
cancer who smoked, found that
patients who received RT in the
morning had significant reduction
of mucositis compared with those
who received treatment in the
afternoon - the effects of smoking
can be acute reversible
(Bjarnason et al 2009)
Radiation therapy
Patients with cervical cancer who received RT (n = 3489)
Correlation between smoking and major complications in
the rectum, bladder and bowel
(Eifel et al, 2002)
Patients with prostate cancer (n = 836)
Smoking during treatment was associated with
increased risk of diarrhea and colic.
Quitting smoking eliminated these risks to a large extent
(Alsadius et al, 2011)
Chemotherapy
Altered metabolism and
pharmacokinetics – lower response
rates and higher risk of complications
ASCO 2012, Dresler & Gritz 2001, Hamilton et al 2006
Impaired immune system increased infections
Aggravation of common side effects
such as weight loss, cachexia, fatigue,
lung - and cardiac toxicity
Gritz et al 2007
Smoking affects the metabolism (mitochondrial
signals/apoptosis/angiogenesis) and pharmacokinetics (Waller et al 2010).
Increased risk of secondary malignancy
Smokers have a higher risk for developing
secondary cancers
Khuri et al (ENT) 2006, Obedian et al (Ca mammae) 2000, Park et al 2007,
van den Belt- Dusedout (ca testis) 2007
Smoking combined with RT and chemotherapy may act
in synergy and increase the risk of secondary cancer
Boorjian et al (Ca prostata) 2007, Ford el at (Ca mammae) 2003,
Travis et al (Hodgkins) 2002
Secondary cancer - some examples
Patients with Hodgkin who smoked had a higher risk of
developing lung cancer after chemotherapy and / or RT
Travis et al 2002
The same can be seen in survivors of breast cancer
Ford et al 2003
Retrospective study (n=29,795)
59 % higher risk of all SC and
102 % higher risk of smoking-related SC
Tabuchi et al 2013
Smoking cessation is associated with;
Improved treatment outcome
Longer survival
Less side effects
Fewer infections
Fewer hospital days
Improved respiration and circulation
Improved energy and quality of life
ASCO,2012, Warren 2013, Zevallos et al 2009, Chen et al 2010, Li Chin
et al 2011, Peppone et al 2011, Balduyck et al, Toll et al 2013
Diagnostic groups and smoking cessation
- some examples
Patients with lung cancer who
stopped smoking after diagnosis
had a reduced risk of mortality
Chan el at 2010
Breast cancer patients who
stopped smoking had a reduced
risk of developing a new primary
breast cancer
Li et al 2009
So - what do we do?
It is not enough to say;
“You better quit smoking!"
and leave the patient alone with the problem
Patients calls for clear, formalized
and fact based guidance and
follow-up over time.
Patients want to be encouraged to
quit smoking early in the course
Hsu et al 2011, Dresler 2003
Identify the smoking habits
To what extent, when during the day (degree of dependence),
in what situations?
Motivate smokers to quit
Inform that tobacco use will reduce the effectiveness of
treatment and that the most important the patient can do
is to stop using tobacco (smoking, snuff and chewing tobacco)
Table 3: Advice to those who are not yet ready to quit
Counselling + smoking cessation drugs = true
Those who get professional help in combination with nicotine
replacement therapy (NRT) are more likely to successfully quit smoking
To succeed
Those who receive counselling in
combination with smoking cessation
drugs are more likely to successfully
quit smoking
Correct medicine and dose
Combining different drugs or
increasing the dose
Swap medicines
Table 4: Measures based on motivation and nicotine addiction
Motivation
Level 1
Level 2
Level 3
Are you ready
to quit smoking
now?
Recommendations for
low nicotine
addiction
Recommendations for
medium nicotine
addiction
Recommendations for
strong nicotine
addiction
YES
Counselling;
The benefits of quitting.
Brochures for distribution:
Patient information about
smoking cessation (OUS)
Preparing for smoking
cessation
As on level 1
As on level 1 and 2.
In addition;
Recommend nicotine
replacement therapy (NRT).
Consider higher doses of
the NEP and optionally
combine various drugs.
Close monitoring.
Brochures for distribution:
Drugs for smoking
cessation
Referring to Quitline
(tel: 800 400 85)
NO
Counselling;
The benefits of quitting.
Brochures for distribution:
Patient information about
smoking cessation (OUS)
Preparing for smoking
cessation
Brochures for distribution:
Drugs for smoking
cessation
As on level 1
As on level 1 and 2.
Consider recommending
NRT to reduce tobacco use
Address tobacco use and
motivation at every visit /
hospitalization
Brochures for distribution:
Drugs by smoking cessation
Brochures for distribution:
Drugs by smoking
cessation
Smoking cessation drugs
Nicotine replacement therapy (NRT)
Reduces withdrawal symptoms
Transdermal patch, gum, lozenges, inhaler
Mild side effects, available without prescription
Varinecline
Makes you unable to enjoy nicotine
Prescription is required
Bupropion
Increases the ability to refrain from smoking
Antidepressant
Prescription is required
Table 5: Smoking cessation drugs
Part 1: Nicotine replacement therapy (NRT)
Part 2: Medication not containing nicotine
Quitline supervising
Don’t have to be determined in
advance of referral
Professional counselling
Confidentiality
One year of follow-up
Free of charge
Three main areas to improve the care
of smokers with cancer
1. Telling the facts: the impact of
smoking on the outcome of
treatment to make it possible for
patients to make informed choices
about smoking
2. Providing guidance and encourage
a safe and effective smoking
cessation
3. Help prevent and reduce
withdrawal symptoms
An ethical issue
” I know something that can make the treatment work
better and increases the chance of survival, but I
think that it will be too difficult for you right now,
so let's not discuss it .... "
Patient participation
To quit smoking is an opportunity for
patients with cancer to exert control
over their health and life during a
period of time when a sense of
control are deeply challenged ...
Thank you for listening
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