Addressing tobacco use in patients with cancer: a survey of American Society of Clinical Oncology members

PURPOSE

Assessing tobacco use and providing cessation support is recommended by the American Society for Clinical Oncology (ASCO). The purpose of this study was to evaluate practice patterns and perceptions of tobacco use and barriers to providing cessation support for patients with cancer.

METHODS

In 2012, an online survey was sent to 18,502 full ASCO members asking about their practice patterns regarding tobacco assessment, cessation support, perceptions of tobacco use, and barriers to providing cessation support for patients with cancer. Responses from 1,197 ASCO members are reported.

RESULTS

At initial visit, most respondents routinely ask patients about tobacco use (90%), ask patients to quit (80%), and advise patients to stop using tobacco (84%). However, only 44% routinely discuss medication options with patients, and only 39% provide cessation support. Tobacco assessments decrease at follow-up assessments. Most respondents (87%) agree or strongly agree that smoking affects cancer outcomes, and 86% believe cessation should be a standard part of clinical cancer care. However, only 29% report adequate training in tobacco cessation interventions. Inability to get patients to quit (72%) and patient resistance to treatment (74%) are dominant barriers to cessation intervention, but only 8% describe cessation as a waste of time.

CONCLUSION

Among ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support. Interventions are needed to increase access to tobacco cessation support for patients with cancer.

Addressing tobacco use and cessation in cancer patients: Practices, perceptions, and barriers reported by oncology providers

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Background: Tobacco use is associated with adverse outcomes in cancer patients, but there are limited data on tobacco cessation support by oncology providers. Methods: Duplicate surveys were sent to the membership of the International Association for the Study of Lung Cancer (IASLC) and the American Society of Clinical Oncology (ASCO) asking about tobacco assessment and cessation practices, perceptions of tobacco use by cancer patients, and barriers to implementing tobacco cessation. The results of 1,507 responses from IASLC and 1,197 responses from ASCO are reported. Results: At initial consult, most respondents asked about tobacco use (90% in both surveys), asked if smokers would quit tobacco use (79-80%), advised patients to stop smoking (81-82%). Most respondents felt that tobacco affects cancer outcomes (87-92%) and that tobacco cessation should be a standard part of clinical care (86-90%). However, few discussed medication options (40-44%) or actively provided smoking cessation assistance (39% in both surveys). Fewer respondents asked about tobacco use at follow-up and few reported adequate tobacco cessation training (29-33%). Dominant barriers to providing cessation interventions included patient resistance to cessation treatment (67-74%) and inability to get patients to quit tobacco use (58-72%), but very few believed tobacco cessation was a waste of time (8-12%). Lack of time, reimbursement, lack of training, and lack of resources were reported as barriers in less than 50% of respondents. Conclusions: Oncology providers feel tobacco affects cancer outcomes and cessation should be a standard part of clinical care. Most assess tobacco use, but few discuss medication options or provide active cessation support. Efforts are needed to improve cessation methods in cancer patients and to improve access to tobacco cessation support for cancer patients.

Two lipids based on lipidomics as novel biomarkers for early detection of squamous cell lung cancer

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Background: Lipids play roles in membrane structure, energy storage, and signal transduction as well as lung cancer. Lipidomics, a new technology aims to measure all the lipids in a cell, has not been applied to diagnostic test development for a variety of cancer types. Here, we adopt lipidomics as a means to identify plasma lipid markers for the early detection of lung cancer and complement CT-based methods for lung cancer screening. Methods: Using mass spectrometry, we profiled 390 individual lipids in a training discovery cohort comprised of cohorts that were either at “high-risk” for lung cancer (n=22) and squamous cell carcinoma at early stages (n=22). Cases had a minimum of two years clinical follow-up and were matched in terms of race, sex, age and smoking status. Gain ratio feature selection and local weighted classification model were employed to find the best training classifier, which was further validated against an additional cohort, including high-risk individuals (n= 20) and squamous cell carcinoma patients (n=17). Results: In the training discovery stage, we found 20 distinct lipids that were significantly distributed between high-risk and cases of squamous cell carcinoma. We further defined a two lipid marker panel had a training accuracy at 95.5% sensitivity, 90.9% specificity and 95.2% AUC (Area under ROC curve). The validation accuracy against the additional cohort is 100.0% sensitivity, 90.0% specificity and 99.0% AUC (Table). The power for sample size we used in both discovery training and validation stages were over 90%. Conclusions: Using lipidomics we identified two lipid markers capable of discerning cases of squamous cell carcinoma from individuals at high risk for lung cancer, with a high sensitivity, specificity and accuracy. The markers maybe further developed as a quick, safe blood test for early diagnosis of squamous cell lung cancer and reduce unnecessary follow-up imaging or invasive procedures. [Table: see text]

Not significant but important

Armstrong and colleagues report the result of a large Phase IIb randomized trial evaluating the effectiveness of a preparation of the Bowman Birk Inhibitor compared with an oral placebo in reversing the extent of oral leukoplakia as measured visually by pathology or a battery of intermediate end points. In this editorial, we review the report of this negative clinical trials result to highlight the clinical trial process used in evaluating this previously promising chemoprevention agent. Publishing this report is important to address concerns with publication bias. The challenges in running a chemoprevention trial are reviewed with suggestions to enhance progress going forward. Conceptually, developing drugs to intercept the early stages of carcinogenesis is very attractive, but progress in this area has been slow. Two opportunities to overcome this reality are discussed. These measures include the broader use of neoadjuvant, window-of-opportunity trials with new candidate chemoprevention agents to get more textured information about the mechanistic impact of the drug exposure in previously untreated early tumor tissue. In addition, we discuss the use of new intermediate end point markers such as with optical imaging tools to obtain a more objective and quantitative assessment of drug response.

An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost

Lung cancer screening is not established as a public health practice, yet the results of a recent large randomized controlled trial showed that screening with low-dose spiral computed tomography reduces lung cancer mortality. Using actuarial models, this study estimated the costs and benefits of annual lung cancer screening offered as a commercial insurance benefit in the high-risk US population ages 50-64. Assuming current commercial reimbursement rates for treatment, we found that screening would cost about $1 per insured member per month in 2012 dollars. The cost per life-year saved would be below $19,000, an amount that compares favorably with screening for cervical, breast, and colorectal cancers. Our results suggest that commercial insurers should consider lung cancer screening of high-risk individuals to be high-value coverage and provide it as a benefit to people who are at least fifty years old and have a smoking history of thirty pack-years or more. We also believe that payers and patients should demand screening from high-quality, low-cost providers, thus helping set an example of efficient system innovation.

The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups

OBJECTIVE

Lung cancer is the leading cause of cancer death in North America. Low-dose computed tomography screening can reduce lung cancer-specific mortality by 20%.

METHOD

The American Association for Thoracic Surgery created a multispecialty task force to create screening guidelines for groups at high risk of developing lung cancer and survivors of previous lung cancer.

RESULTS

The American Association for Thoracic Surgery guidelines call for annual lung cancer screening with low-dose computed tomography screening for North Americans from age 55 to 79 years with a 30 pack-year history of smoking. Long-term lung cancer survivors should have annual low-dose computed tomography to detect second primary lung cancer until the age of 79 years. Annual low-dose computed tomography lung cancer screening should be offered starting at age 50 years with a 20 pack-year history if there is an additional cumulative risk of developing lung cancer of 5% or greater over the following 5 years. Lung cancer screening requires participation by a subspecialty-qualified team. The American Association for Thoracic Surgery will continue engagement with other specialty societies to refine future screening guidelines.

CONCLUSIONS

The American Association for Thoracic Surgery provides specific guidelines for lung cancer screening in North America.

Development of The American Association for Thoracic Surgery guidelines for low-dose computed tomography scans to screen for lung cancer in North America: recommendations of The American Association for Thoracic Surgery Task Force for Lung Cancer Screening and Surveillance

OBJECTIVE

The study objective was to establish The American Association for Thoracic Surgery (AATS) lung cancer screening guidelines for clinical practice.

METHODS

The AATS established the Lung Cancer Screening and Surveillance Task Force with multidisciplinary representation including 4 thoracic surgeons, 4 thoracic radiologists, 4 medical oncologists, 1 pulmonologist, 1 pathologist, and 1 epidemiologist. Members have engaged in interdisciplinary collaborations regarding lung cancer screening and clinical care of patients with, and at risk for, lung cancer. The task force reviewed the literature, including screening trials in the United States and Europe, and discussed local best clinical practices in the United States and Canada on 4 conference calls. A reference library supported the discussions and increased individual study across disciplines. The task force met to review the literature, state of clinical practice, and recommend consensus-based guidelines.

RESULTS

Nine of 14 task force members were present at the meeting, and 3 participated by telephone. Two absent task force members were polled afterward. Six unanimous recommendations and supporting work-up algorithms were presented to the Council of the AATS at the 2012 annual meeting in San Francisco, California.

CONCLUSIONS

Annual lung cancer screening and surveillance with low-dose computed tomography is recommended for smokers and former smokers with a 30 pack-year history of smoking and long-term lung cancer survivors aged 55 to 79 years. Screening may begin at age 50 years with a 20 pack-year history of smoking and additional comorbidity that produces a cumulative risk of developing lung cancer of 5% or greater over the following 5 years. Screening should be undertaken with a subspecialty qualified interdisciplinary team. Patient risk calculator application and intersociety engagement will provide data needed to refine future lung cancer screening guidelines.

Abstract IA19: New opportunities to the personalization and management of early lung cancer

Lung cancer is the most lethal cancer across the globe with 5-year mortality rates from 80 to over 90% related to the frequency of metastatic disease at initial diagnosis. While metastatic disease is generally incurable, early lung cancer when found still localized to the airways, can frequently be cured. A recent NCI-sponsored, randomized trial of helical CT compared to chest X-ray screening in a high risk cohort reported that the CT arm resulted in a 20% reduction in lung cancer mortality. Coupled with the recent comprehensive revision of lung cancer staging classification, there is a much clearer understanding of the relationship between primary tumor size and lung cancer outcome. The finding that smaller lung cancers are more frequently curable provides a firm conceptual framework for population-based early lung cancer detection strategies as a productive approach to significantly improve lung cancer outcomes.

As was demonstrated by reports from both I-ELCAP and the NELSON clinical trials groups, detection rates of stage I lung cancer with helical CT could exceed 70%. Further, the expense and morbidity of invasive diagnostic work-up strategy could be efficient focused based on the suggestion by Yankelevitz and co-workers to use measurement of nodule growth rate on serial CT scans as a biomarker to identify clinically aggressive lung cancers. In this fashion as reported by van Klaveren and co-workers, volumetric determination of suspected lung cancers could enable efficient and accurate lung cancer case detection.

The surgical management of early stage lung cancers is increasingly employing video-assisted thoroscopic surgery. Recent studies demonstrate lower complications and more favorable operative mortality rates compared to standard, open thorocotomy approaches. The net effect of these developments is to reduce the possibility of over-treatment in the lung cancer screening setting. These surgical procedures do provide sufficient primary tumor tissue which allows comprehensive molecular analysis of the tumor to identify critical signaling pathways.

As the evolution of effective and efficient early lung cancer management unfolds, opportunities exist to better define the relevant at-risk population for screening approaches with the ability to calibrate the frequency of screening relative to the measured risk profile. Information from the imaging and tumor tissue evaluation of detected cases may also provide insight as to the molecular underpinnings of the cancer. This characterization of the primary tumor may subsequently guide the development of more tailored adjuvant therapies and eventually chemopreventive strategies that would be targeted to the specific pathogenic mechanisms of lung carcinogenesis.

The continuous improvement of early lung cancer management is an appropriate area to apply the process improvement strategies proposed by the Institute of Medicine in their Learning Health System approach. In this way, the component elements of the screening process can be optimized and personalized to allow overall progress in advancing public health benefit with CT-based lung cancer screening.

hnRNP A2/B1 modulates epithelial-mesenchymal transition in lung cancer cell lines

Heterogeneous nuclear ribonucleoprotein A2/B1 (hnRNP A2/B1) has been reported to be overexpressed in lung cancer and in other cancers such as breast, pancreas, and liver. However, a mechanism linking hnRNP A2/B1 overexpression and progression to cancer has not yet been definitively established. To elucidate this mechanism, we have silenced hnRNPA2/B1 mRNA in non-small-cell lung cancer cell lines A549, H1703, and H358. These cell lines present different levels of expression of epithelial-to-mesenchymal transition (EMT) markers such as E-cadherin, fibronectin, and vimentin. Microarray expression analysis was performed to evaluate the effect of silencing hnRNP A2/B1 in A549 cells. We identified a list of target genes, affected by silencing of hnRNP A2/B1, that are involved in regulation of migration, proliferation, survival, and apoptosis. Silencing hnRNP A2/B1 induced formation of cell clusters and increased proliferation. In the anchorage-independent assay, silencing hnRNP A2/B1 increased colony formation by 794% in A549 and 174% in H1703 compared with a 25% increase in proliferation, in both cell lines, in a two-dimensional proliferation assay. Silencing hnRNP A2/B1 decreased migration in intermediate cell line A549 and mesenchymal cell line H1703; however, no changes in proliferation were observed in epithelial cell line H358. Silencing hnRNP A2/B1 in A549 and H1703 cells correlated with an increase of E-cadherin expression and downregulation of the E-cadherin inhibitors Twist1 and Snai1. These data suggest that expression of hnRNP A2/B1 may play a role in EMT, in nonepithelial lung cancer cell lines A549 and H1703, through the regulation of E-cadherin expression.

A quantitative method for estimating individual lung cancer risk

RATIONALE AND OBJECTIVES

Lung cancer is caused primarily by repeated exposure to carcinogenic particulate matter and noxious gasses with high particulate deposition localized to airway bifurcations and the lung periphery. The quantitative measurement and analysis of these sites has the potential to stratify lung cancer risk. The aim of this preliminary study was to assess the performance of a new method for estimating individual lung cancer risk based on the analysis of airway bifurcations on high-resolution (HR) computed tomographic (CT) scanning and spirometry.

MATERIALS AND METHODS

One hundred eight subjects with spirometry and thin-slice CT data were selected from a CT screening study including 15 patients with early lung cancer and 93 age-matched and pack-year-matched controls. A subset of seven patients with cancer and 72 controls were scanned with 1-mm CT slice thickness, representing an HR case subset. A quantitative lung cancer risk index method was developed on the basis of airway bifurcation x-ray attenuation combined with the ratio of forced expiratory volume in 1 second to forced vital capacity. Cochran-Mantel-Haenszel and conditional logistic regression tests were used to analyze performance.

RESULTS

Cochran-Mantel-Haenszel crude analysis revealed a cancer detection sensitivity and specificity of 67% and 72% for all cases and 100% and 73% for the HR case subset, respectively. Conditional logistic regression showed that a 0.0328 increase in lung cancer risk index was associated with odds ratios of 1.84 (95% confidence interval, 1.18-2.85) for the full data set (P = .0067) and 2.89 (95% confidence interval, 1.02-8.19) for the HR subset (P = .0467).

CONCLUSIONS

A preliminary evaluation of a new lung cancer risk estimation method based on thin slice CT and spirometry showed a statistically significant association with lung cancer.

The Liverpool Statement 2005: priorities for the European Union/United States spiral computed tomography collaborative group

The Liverpool Statement 2005 was developed at the Fourth International Lung Cancer Molecular Biomarkers Workshop in Liverpool (October 27-29, 2005) and focused on the priorities for the European Union/United States (EU-US) Spiral Computed Tomography (CT) Collaborative Group. The application of spiral CT technology for early lung cancer screening has gained enormous momentum in the past 5 years. The EU-US Spiral CT Collaboration was initiated in 2001 in Liverpool, and subsequent meetings throughout Europe have resulted in the development of collaborative protocols and minimal data sets that provide a mechanism for the different trial groups to work together, with the ultimate aim to pool results. Considerable progress has been made with major national screening trials in the U.S. and Europe, which include IELCAP, NLST, and NELSON. The major objective of this international collaboration is the planned cross-analysis of the individual studies after they are reported. The EU-US researchers have agreed to a number of long-term objectives and to explore strategic areas for harmonization of complementary investigations.