Cognitive testing of tobacco use items for administration to patients with cancer and cancer survivors in clinical research

The Association Between an Electronic Health Record (EHR)-Embedded Frailty Index and Patient-Reported Outcomes Among Patients with Metastatic Non-Small-Cell Lung Cancer on Immunotherapy: A Brief Report

Background: While frailty is a well-established predictor of overall mortality among patients with metastatic non-small cell lung cancer (mNSCLC), its association with patient-reported outcomes is not well-characterized. The goal of this study was to examine the association between an electronic frailty index (eFI) score and patient-reported outcome measures along with prognostic awareness among patients with mNSCLC receiving immunotherapy. Methods: In a cross-sectional study, patients with mNSCLC who were on immunotherapy completed the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ-C30) and the National Cancer Institute Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). We utilized bivariate analyses to compare quality of life, symptoms, supportive services, and prognostic awareness among 3 groups defined by e-frailty status. Results: Sixty patients (mean age 62.5 years, 75% Caucasian, 60% women) participated. Most patients were pre-frail (68%), with 13% being frail and 18% non-frail. Pre-frail and frail patients had significantly lower physical function scores (mean 83.9 fit vs 74.8 pre-frail vs 60.0 frail, P = .04) and higher rates of self-reported pain (75% frail vs 41.5% pre-frail vs 18.2% fit; P = .04) compared to non-frail patients. We found no differences in palliative referral rates. Conclusion: Pre-frail and frail mNSCLC patients identified by the eFI have higher rates of pain and physical functional impairments than non-frail patients. These findings highlight the importance of emphasizing preventive interventions targeting social needs, functional limitations, and pain management, especially among pre-frail patients to reduce further decline.

Motivating smoking cessation among patients with cancers not perceived as smoking-related: a targeted intervention

PURPOSE

Smoking after cancer impairs cancer treatment outcomes and prognosis, regardless of cancer type. Prior data suggest that patients with cancers other than lung or head/neck cancer had lower cessation motivation, which in turn predicted lower smoking abstinence. This study evaluated feasibility for a future efficacy trial and assessed the acceptability of brief self-help materials, targeted by cancer type, to enhance cessation motivation.

METHODS

Patients had a diagnosis of skin melanoma, breast, bladder, colorectal, or gynecological cancers within ≤ 6 months, smoked ≥ 1 cigarette in the past month, and were not currently participating in a cessation program. After completing a baseline assessment, participants received the booklet corresponding to their cancer type. Follow-ups were conducted 1 week and 1 month post-intervention.

RESULTS

Among 118 patients potentially eligible, 109 were successfully contacted and 53 patients were eligible and all consented. Among consenting patients, 92.5% completed baseline, and 90.6% received the intervention. Among patients receiving the intervention, 91.7% completed all study procedures and follow-up. At 1 month, 87.5% reported reading the booklet and 92.8% rated it as good/excellent. Motivation to quit smoking increased over time among those with lower motivation at baseline, 33.3% sought smoking cessation assistance, and 25.0% were smoke-free 1 month post-intervention.

CONCLUSION

This study demonstrated the feasibility and acceptability of the first intervention developed for patients with cancers not typically associated with smoking. This low-cost and easy to disseminate intervention has potential to increase motivation to quit smoking among patients with cancers not typically perceived as smoking-related.

Overcoming Delays in the Progress against Cancer: Identifying Tobacco Use among Cancer Patients Enrolled in Clinical Trials

Though smoking causes adverse cancer treatment outcomes and smoking cessation can improve survival, prior literature demonstrates deficits in collecting tobacco use information in clinical trials. Results by Streck and colleagues represent a thorough structured assessment of tobacco use and alternative tobacco product use in patients enrolled in cooperative group trials. Among patients with predominantly non-tobacco related cancers, observations demonstrate that approximately 27% of patients reported using one or more forms of tobacco use after diagnosis. Alternative tobacco use was reported by many patients, including patterns of dual use. Results demonstrate the feasibility of collecting comprehensive structured tobacco use information, and further support the need to address tobacco and cessation even among patients with non-tobacco related cancers. See related article by Streck and colleagues, Cancer Epidemiol Biomarkers Prev 2023;32:1552-57.

Effectiveness of a computer-facilitated intervention on improving provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting: A pilot study

INTRODUCTION

Effective tobacco treatments are available but are often not delivered to individuals with an actual or potential diagnosis of thoracic malignancy. The specific aims of this study were to identify the prevalence of tobacco use and examine the effectiveness of the Clinical and community Effort Against Smoking and secondhand smoke Exposure (CEASE), a system-level computer-facilitated intervention, to improve provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting.

METHODS

A pre-post-test design was used to assess the effectiveness of CEASE. A 3-step approach was used to integrate tobacco treatment into routine care: ask about tobacco use, assist with cessation, and refer to a quitline. An end-of-visit survey was conducted to collect prevalence of tobacco use and delivery of tobacco treatment. Descriptive statistics and Fisher's exact test were used for analysis.

RESULTS

A total of 218 individuals were enrolled; 105 participants were in usual care (UC) and 113 were in the CEASE group. Of those who enrolled, 27.6% were never smokers in UC and 27.7% in CEASE, 60% were former smokers in UC and 50% in CEASE, and 12.4% were current smokers in UC and 21.4% in CEASE. Significant differences were noted in delivery of tobacco treatment with 15.4% having received tobacco treatment in UC compared to 62.5% in CEASE (p<0.004).

CONCLUSIONS

A computer-facilitated intervention increased provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting. This intervention provided a low-resource approach that has the potential to be scaled and implemented more broadly.

Real-world analysis of the relationships between smoking, lung cancer stigma, and emotional functioning

INTRODUCTION

People diagnosed with lung cancer experience high rates of distress, which can be compounded by the stigma of the disease. This study assessed a real-world population to understand patient-reported emotional functioning, types of stigma experienced, and relationship with smoking history.

METHODS

Questionnaires using validated survey tools assessing demographics, smoking history, stigma, and quality of life (EORTC QLQ-C30 Emotional Functioning Scale) were analyzed from 539 global participants in the Lung Cancer Registry between November 2019 and July 2022. The associations between smoking history and self-reported internalized and perceived stigma and constrained disclosure of lung cancer diagnosis, as well as the potential impact of stigma on emotional functioning, were examined using multivariable logistic regression models.

RESULTS

Among the broad geographic mix of study participants, all types of lung cancer stigma were associated with decreased emotional functioning due to a combination of factors including depression, anxiety, stress, and irritability. Participants who reported a history of current or former smoking experienced higher levels of internalized stigma and perceived stigma. Constrained disclosure about a diagnosis was common, associated with decreased emotional functioning, and not related to a history of smoking. Smoking status itself was not associated with reduced emotional functioning, implicating the role of stigma in distress.

CONCLUSIONS

In this study, all types of lung cancer stigma were associated with clinically important decreases in emotional functioning. This impact was not dependent on smoking history. Internalized and perceived stigma were associated with the presence of a smoking history. These findings have implications for proper psychosocial care of people diagnosed with lung cancer.

Risk for Suicidal Behavior After Psychiatric Hospitalization Among Sexual and Gender Minority Patients

Importance

The months following inpatient psychiatric hospitalization are a period of high risk for suicidal behavior. Sexual and gender minority (SGM) individuals have elevated risk for suicidal behavior, but no prior research has examined whether SGM inpatients have disproportionate risk for suicidal behavior following discharge from psychiatric hospitalization.

Objectives

To evaluate whether SGM patients have elevated risk for suicidal behavior following discharge from psychiatric hospitalization compared with heterosexual and cisgender patients and to examine whether differences in risk across groups were accounted for by demographic characteristics and clinical factors known to be associated with suicidal behavior.

Design, Setting, and Participants

This prospective cohort study was conducted from August 2017 to July 2021 among inpatients aged 18 to 30 years who were voluntarily enrolled during psychiatric hospitalization. The study was conducted at an inpatient psychiatric hospital, with prospective data collected via follow-up visits and electronic health records.

Main Outcomes and Measures

Onset and/or recurrence of suicidal behavior following discharge from psychiatric hospitalization, assessed at follow-up visits and through electronic health records.

Results

A total of 160 patients were included, with 56 sexual minority (SM) and 15 gender minority (GM) patients. The median (IQR) age of the patients was 23.5 (20.4-27.6) years, 77 (48%) reported male sex assigned at birth, and 114 (71%) identified their race as White. During the follow-up period, 33 suicidal behavior events occurred (among 21% of patients). SM (hazard ratio [HR], 2.02; 95% CI, CI, 1.02-4.00; log-rank P = .04) and GM (HR, 4.27; 95% CI, 1.75-10.40; log-rank P < .001) patients had significantly higher risk for suicidal behavior compared with their heterosexual and cisgender counterparts, respectively, in bivariable analyses. Risk between SM and heterosexual patients was not different after controlling for demographic characteristics and clinical factors associated with suicidal behavior. GM patients exhibited elevated risk during the 100 days following discharge even after controlling for demographic and clinical characteristics (HR, 3.80; 95% CI, 1.18-11.19; P = .03).

Conclusions and Relevance

Within this cohort study of psychiatric patients, SGM patients had higher risk for suicidal behavior than non-SGM patients following discharge. While SM patients' risk was accounted for by clinical characteristics, GM patients' risk for suicidal behavior was not accounted for by their acute psychiatric state on admission. Future studies with larger subsamples of GM individuals are needed, and inpatient clinicians must attend to the unique needs of SGM individuals to ensure they receive affirming services.

Palliative care use and utilization determinants among patients treated for advanced stage lung cancer care in the community and academic medical setting

PURPOSE

Despite clinical guidelines, palliative care is underutilized during advanced stage lung cancer treatment. To inform interventions to increase its use, patient-level barriers and facilitators (i.e., determinants) need to be characterized, especially among patients living in rural areas or those receiving treatment outside academic medical centers.

METHODS

Between 2020 and 2021, advanced stage lung cancer patients (n = 77; 62% rural; 58% receiving care in the community) completed a one-time survey assessing palliative care use and its determinants. Univariate and bivariate analyses described palliative care use and determinants and compared scores by patient demographic (e.g., rural vs. urban) and treatment setting (e.g., community vs. academic medical center) factors.

RESULTS

Roughly half said they had never met with a palliative care doctor (49.4%) or nurse (58.4%) as part of cancer care. Only 18% said they knew what palliative care was and could explain it; 17% thought it was the same as hospice. After palliative care was distinguished from hospice, the most frequently cited reasons patients stated they would not seek palliative care were uncertainty about what it would offer (65%), concerns about insurance coverage (63%), difficulty attending multiple appointments (60%), and lack of discussion with an oncologist (59%). The most common reasons patients stated they would seek palliative care were a desire to control pain (62%), oncologist recommendation (58%), and coping support for family and friends (55%).

CONCLUSION

Interventions should address knowledge and misconceptions, assess care needs, and facilitate communication between patients and oncologists about palliative care.

Protocol for a randomized controlled trial of the Enhanced Smoking Cessation Approach to Promote Empowerment (ESCAPE) digitalized intervention to promote lung health in high-risk individuals who smoke

Low dose computed tomography (LDCT) is an effective screening test to decrease lung cancer deaths. Lung cancer screening may be a teachable moment helping people who smoke to quit, which may result in increased benefit of screening. Innovative strategies are needed to engage high-risk individuals in learning about LDCT screening. More precise methods such as polygenic risk scores quantify genetic predisposition to tobacco use, and optimize lung health interventions. We present the ESCAPE (Enhanced Smoking Cessation Approach to Promote Empowerment) protocol. This study will test a smoking cessation intervention using personal stories and a lung cancer screening decision-aide compared to standard care (brief advice, referral to a quit line, and a lung cancer screening decision-aide), examine the relationship between a polygenic risk score and smoking abstinence, and describe perceptions about integration of genomic information into smoking cessation treatment. A randomized controlled trial followed by a sequential explanatory mixed methods approach will compare the efficacy of the interventions. Interviews will add insight into the use of genomic information and risk perceptions to tailor smoking cessation treatment. Two-hundred and fifty individuals will be recruited from primary care, community-based organizations, mailing lists and through social media. Data will be collected at baseline, 1, 3 and 6-months. The primary outcomes are 7-day point prevalence smoking abstinence and stage of lung cancer screening at 6-months. The results from this study will provide information to refine the ESCAPE intervention and facilitate integration of precision health into future lung health interventions. Clinical trial registration number: NCT0469129T.

Evaluation of Cancer Deaths Attributable to Tobacco in California, 2014-2019

IMPORTANCE

California's tobacco control efforts have been associated with a decrease in cancer mortality, but these estimates are based on smoking prevalence of the general population. Patient-level tobacco use information allows for more precise estimates of the proportion of cancer deaths attributable to smoking.

OBJECTIVE

To calculate the proportion (smoking-attributable fraction) and number (smoking-attributable cancer mortality) of cancer deaths attributable to tobacco use using patient-level data.

DESIGN, SETTING, AND PARTICIPANTS

The smoking-attributable fraction and smoking-attributable cancer mortality were calculated for a retrospective cohort of patients whose cancer was diagnosed from 2014 to 2019 with at least 1 year of follow-up using relative risks from large US prospective studies and patient-level smoking information. Follow-up continued through April 2022. A population-based cohort was identified from the California Cancer Registry. Participants included adults aged 20 years and older with a diagnosis of 1 of the 12 tobacco-related cancers (oral cavity or pharynx, larynx, esophagus, lung, liver, stomach, pancreas, kidney, bladder, colon or rectum, cervix, and acute myeloid leukemia).

EXPOSURES

Tobacco use defined as current, former, or never.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the smoking-attributable fraction and smoking-attributable cancer mortality for each of the 12 tobacco-related cancers over 2 time periods (2014-2016 vs 2017-2019) and by sex.

RESULTS

Among 395 459 patients with a tobacco-related cancer, most (285 768 patients [72.3%]) were older than 60 years, the majority (228 054 patients [57.7%]) were non-Hispanic White, 229 188 patients were men (58.0%), and nearly one-half (184 415 patients [46.6%]) had lung or colorectal cancers. Nearly one-half of the deaths (93 764 patients [45.8%]) in the cohort were attributable to tobacco. More than one-half (227 660 patients [57.6%]) of patients had ever used tobacco, and 69 103 patients (17.5%) were current tobacco users, which was higher than the proportion in the general population (11.7%). The overall smoking-attributable fraction of cancer deaths decreased significantly from 47.7% (95% CI, 47.3%-48.0%) in 2014 to 2016 to 44.8% (95% CI, 44.5%-45.1%) in 2017 to 2019, and this decrease was seen for both men and women. The overall smoking-attributable cancer mortality decreased by 10.2%.

CONCLUSIONS AND RELEVANCE

California still has a substantial burden of tobacco use and associated cancer. The proportion of cancer deaths associated with tobacco use was almost double what was previously estimated. There was a modest but significant decline in this proportion for overall tobacco-associated cancers, especially for women.

Reporting of tobacco use and tobacco-related analyses in cancer cooperative group clinical trials: a systematic scoping review

BACKGROUND

Continued smoking after a diagnosis of cancer negatively impacts cancer outcomes, but the impact of tobacco on newer treatments options is not well established. Collecting and evaluating tobacco use in clinical trials may advance understanding of the consequences of tobacco use on treatment modalities, but little is known about the frequency of reporting and analysis of tobacco use in cancer cooperative clinical trial groups.

PATIENTS AND METHODS

A comprehensive literature search was conducted to identify cancer cooperative group clinical trials published from January 2017-October 2019. Eligible studies evaluated either systemic and/or radiation therapies, included ≥100 adult patients, and reported on at least one of: overall survival, disease/progression-free survival, response rates, toxicities/adverse events, or quality-of-life.

RESULTS

A total of 91 studies representing 90 trials met inclusion criteria with trial start dates ranging from 1995 to 2015 with 14% involving lung and 5% head and neck cancer patients. A total of 19 studies reported baseline tobacco use; 2 reported collecting follow-up tobacco use. Seven studies reported analysis of the impact of baseline tobacco use on clinical outcomes. There was significant heterogeneity in the reporting of baseline tobacco use: 7 reported never/ever status, 10 reported never/ex-smoker/current smoker status, and 4 reported measuring smoking intensity. None reported verifying smoking status or second-hand smoke exposure. Trials of lung and head and neck cancers were more likely to report baseline tobacco use than other disease sites (83% versus 6%, P < 0.001).

CONCLUSIONS

Few cancer cooperative group clinical trials report and analyze trial participants' tobacco use. Significant heterogeneity exists in reporting tobacco use. Routine standardized collection and reporting of tobacco use at baseline and follow-up in clinical trials should be implemented to enable investigators to evaluate the impact of tobacco use on new cancer therapies.

A Daily Assessment Study of Smoking Cessation After a Head and Neck Cancer Diagnosis

INTRODUCTION

This intensive longitudinal study describes key events in the process of smoking cessation after a new head and neck cancer (HNC) diagnosis. Prior longitudinal studies show some cancer patients quit, while others continue to smoke, but details about the pattern in which these discrete outcomes arise are scarce. This study is meant to help rectify this gap in the literature.

AIMS AND METHODS

Participants were 42 HNC patients who reported current smoking at enrollment. Participants were recruited from an outpatient oncology clinic and completed a baseline questionnaire prior to begin a 30-day daily assessment.

RESULTS

Few participants (9.52%) achieved 30-day continuous abstinence from smoking. On average, participants reported 9.64 ± 11.93 total days of abstinence. Nearly, all (94.44%, n = 34) participants made at least one quit attempt, with an average of 16.94 ± 11.30 quit attempt days. Fewer participants were able to achieve a 24-hour quit attempt (52.78%, n = 19), with a corresponding average of 5.50 ± 8.69 24-hour days. The median time to first 24-hour quit attempt was 13 days after enrollment. Based on smoking behavioral patterns, participants were categorized into five groups, the most common being "persistent attempters," which involved unsuccessful quit attempts throughout the study. Only 45% of participants (n = 19) used evidence-based treatment, the most common being cessation medication.

CONCLUSIONS

This intensive longitudinal study found that cancer diagnosis can spur a lot of efforts to quit smoking. Unfortunately, this study suggests that many quit attempts are short lived, possibly a result of an absence or insufficient use of evidence-based treatments.

IMPLICATIONS

For adults who are current smokers at the time of cancer diagnosis, there is a high likelihood of persistent cigarette smoking and use of other tobacco products in the weeks and months after a cancer diagnosis. Furthermore, this study shows that while a lot of quit attempts may occur, few are successful, which may be partly attributable to the low use of evidence-based tobacco treatment. Future research with cancer patients should aim to identify predictors of quit attempts and abstinence as well as treatment utilization.

Adolescents' Understanding of Smoking and Vaping Risk Language: Cognitive Interviews to Inform Scale Development

INTRODUCTION

Perceived message effectiveness (PME) is a common metric to understand receptivity to tobacco prevention messages, yet most measures have been developed with adults. We examined adolescents' interpretation of language within candidate items for a new youth-targeted PME measure using cognitive interviewing. We sought to understand the meaning adolescents assigned to our candidate PME items to improve item wording.

AIMS AND METHODS

Participants were 20 adolescents, ages 13-17 years from the United States. Cognitive interviews used a structured guide to elicit feedback on comprehension, answer retrieval, and language regarding a set of Reasoned Action Approach-based survey items that assessed the PME of smoking and vaping prevention ads. We employed thematic analysis to synthesize findings from the interviews.

RESULTS

Interviews identified three main issues related to survey items: ambiguity of language, word choice (risk and other terminology), and survey item phrasing. Adolescents preferred direct, definitive language over more ambiguous phrasing which they saw as less serious (eg, "will" instead of "could"). For risk terminology, they preferred terms such as "harmful" and "dangerous" over "risky," which was viewed as easy to discount. The term "negative effects" was interpreted as encompassing a broader set of tobacco harms than "health effects." Adolescents said that the term "vape" was preferable to "e-cigarette," and identified ways to simplify item wording for greater clarity.

CONCLUSIONS

Tobacco risk terms that appear similar differ in meaning to adolescents, and more direct and unambiguous language is preferred. Our findings informed changes to the PME scale items to improve clarity and reduce measurement error.

IMPLICATIONS

This study adds to the literature on how adolescents interpret tobacco prevention language. Adolescents may interpret terminology differently than adults, which could lead to ambiguity in meaning and thus measurement error. Through cognitive interviewing, we identified and improved the language in a youth-focused PME measure for tobacco and vaping prevention.

Changes in Cigarette Smoking Behavior in Cancer Survivors During Diagnosis and Treatment

INTRODUCTION

Continued cigarette smoking is a critical determinant of outcome in oncology patients, but how the separate events of cancer diagnosis, cancer treatment, and completion of treatment affect smoking behavior in cancer survivors is unknown. This study described such changes, hypothesizing that they would be more pronounced for smoking-related cancers.

METHODS

The Cancer Patient Tobacco Use Questionnaire (CTUQ) was sent to every cancer patient ≥ 18 y old scheduled for outpatient visits at the Mayo Clinic Cancer Center with a current or former history of tobacco use.

RESULTS

From September 2019 to September 2020, 33,831 patients received the CTUQ, and 20,818 (62%) responded. Of the 3007 current smokers analyzed, 34% quit at diagnosis; those with smoking-related cancers were more likely to quit (40% vs. 29%, respectively, p < .001). Among those who did not quit at diagnosis, 31% quit after starting cancer treatment, and those with smoking-related cancers were more likely to quit (35% and 28%, respectively, p = .002) Among those who had quit before the completion of treatment, 13% resumed smoking after treatment ended. In multivariable analysis, patients with smoking-related cancers were more likely to report 30-d point prevalence abstinence from pre-diagnosis to the completion of treatment (adjusted OR 1.98 [95% CI 1.65, 2.36], p < .001).

CONCLUSIONS

Both cancer diagnosis and treatment prompt smoking abstinence, with most maintaining abstinence after treatment is completed. Those with smoking-related cancers are more likely to quit. These results emphasize the need to provide access to tobacco treatment services that can further support cancer patients who smoke.

IMPLICATIONS

Approximately one-third of cancer patients who smoke quit smoking at the time of diagnosis, an additional one-third of patients who had not yet quit did so at the initiation of treatment, and most sustained this abstinence after treatment completion. Patients with smoking-related cancers are more likely to quit. Thus, there are multiple opportunities within the cancer care continuum to intervene and support quit attempts or continued abstinence.

Development of an Advance Care Planning Portal-Based Tool for Community-Dwelling Persons Living With Cognitive Impairment: The ACPVoice Tool

Background: Patient portals can be an innovative and efficient way to engage patients in advance care planning (ACP). However, comprehension and judgment in older adults with cognitive impairment presents several barriers and challenges to engaging in new technology. Our objective was to develop an ACP portal-based tool (ACPVoice) for community-dwelling persons living with cognitive impairment (PLCI) by engaging end-users in the design process. Methods: Two rounds of cognitive interviews were conducted to identify and resolve cognitive issues related to comprehension, judgment, response, and to assess content validity. Purposive sampling was used with the goal of enrolling 15 different participants (five with mild cognitive impairment and five dyads (those with mild dementia and their care partner) in each round to assess respondents' understanding of questions related to advance care planning to be administered via the patient portal. Results: Twenty PLCI (mean age 78.4, 10 females [50%]) and ten care partners (mean age 60.9, 9 females [90%]) completed cognitive interviews between May 2021 and October 2021. The mean Mini-Mental State Examination score for PLCI was 25.6 (SD 2.6). Unclear wording and undefined vague and/or unfamiliar terms were the major issues identified. Revisions to item wording, response options, and instructions were made to improve question comprehension and response as well as navigational ease. Conclusion: Minor changes to the wording, format, and response options substantially improved respondents' ability to interpret the item content of the ACPVoice tool. Dissemination and implementation of the ACPVoice tool could help to engage community-dwelling PLCI in ACP discussions.

Tobacco Use and Response to Immune Checkpoint Inhibitor Therapy in Non-Small Cell Lung Cancer

Tobacco is a known risk factor for lung cancer, and continued tobacco use is associated with poorer outcomes across multiple lung cancer treatment modalities including surgery, chemotherapy and radiation therapy. Less is known about the association of tobacco use and outcomes with immune checkpoint inhibitors (ICIs), which are becoming an important part of the treatment landscape in lung cancer, both in metastatic and curative settings. We reviewed the literature on the association of tobacco and tumor biology as it relates to immunotherapy. We also reviewed the association of tobacco use on outcomes among phase III randomized clinical trials involving ICIs in non-small cell lung cancer (NSCLC). We identified that patients with a smoking history may have a greater benefit with ICI treatment compared to never smokers in both treatment-naïve (HR 0.82, 95% CI 0.69-0.97, vs. HR 1.06, 95% CI 0.81-1.38) and pre-treated (HR 0.79, 95% CI 0.70-0.90 vs. 1.03, 95% CI 0.74-1.43) settings. In trials where smoking status was further defined, ex-smokers appear to demonstrate greater benefit with ICI therapy compared to current smokers (HR 0.78, 95% CI 0.59-1.01 vs. 0.91, 95% CI 0.72-1.14). We conclude by offering our perspective on future directions in this area of research, including implementation of standardized collection and analysis of tobacco use in clinical trials involving ICI therapy in lung cancer and other disease sites, and also evaluating how tobacco may affect toxicities related to ICI therapy. Based on our review, we believe that a patient's history of tobacco smoking does have a role to play in guiding treatment decision making in patients with lung cancer.

Study protocol for a hybrid type 1 effectiveness-implementation trial testing virtual tobacco treatment in oncology practices [Smokefree Support Study 2.0]

BACKGROUND

Persistent smoking among patients diagnosed with cancer is associated with adverse clinical outcomes, yet an evidence-based tobacco use intervention has not been well-integrated into cancer care in community oncology settings. This paper describes the protocol of a nation-wide clinical trial conducted by the ECOG-ACRIN National Cancer Institute (NCI) Community Oncology Research Program (NCORP) Research Base to assess the effectiveness of a virtual tobacco treatment intervention and the process of implementing tobacco treatment in NCORP community oncology settings.

METHODS/DESIGN

This two-arm, multisite (n: 49 NCORP sites) hybrid type 1 effectiveness-implementation randomized controlled trial compares the effectiveness of a Virtual Intervention Treatment (VIT) versus an Enhanced Usual Control (EUC) among English and Spanish speaking patients recently diagnosed with cancer, reporting current smoking and receiving care at a participating NCORP Community or Minority/Underserved Site. The VIT includes up to 11 virtual counseling sessions with a tobacco treatment specialist and up to 12 weeks of nicotine replacement therapy (NRT). The EUC arm receives a referral to the NCI Quitline. The primary study outcome is biochemically confirmed 7-day point prevalence smoking abstinence. Moderators of treatment effect will be assessed. The study evaluates implementation processes from participating NCORP site staff via survey, administrative, and focus group data, including reach, acceptability, appropriateness, fidelity, feasibility, adoption, cost and sustainability outcomes.

DISCUSSION

This trial will generate findings about the effectiveness of an evidence-based virtual tobacco treatment intervention targeting patients diagnosed with cancer and illuminate barriers and facilitators that influence implementing tobacco treatment into community oncology settings nationally. In the era of COVID-19, virtual care solutions are vital for maximizing access and utilization of tobacco treatment delivery.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03808818) on January 18th, 2019; Last update posted: May 21st, 2020.

A descriptive study of cervical cancer survivors' persistent smoking behavior and perceived barriers to quitting

OBJECTIVE

Cervical cancer survivors (CCS) tend to smoke cigarettes at rates much higher than other cancer survivors and women in the general population. However, few studies take a deep dive into the smoking behavior of cervical cancer survivors and none focus on the barriers they experience related to smoking cessation. This study aimed to describe CCS' tobacco use characteristics, quit attempts, and barriers to quit success.

METHOD

In a concurrent mixed-method design, 50 CCS (94% White nonHispanic) who were diagnosed in the past 5 years and were current smokers at diagnosis provided data via standardized questionnaire and semi-structured interview.

RESULTS

More than three-quarters of participants were current smokers at the time of study participation, 25.6% of whom also reported noncigarette tobacco use (e.g., electronic cigarette, cigar, snus). Seventy percent of participants reported making at least one 24 hr quit attempt postdiagnosis, with 61.5% of current smokers preferring to quit without professional advice or counseling and 51.3% preferring to quit without medication assistance. Four themes emerged regarding barriers to smoking cessation: motivation and readiness; confidence and uncertainty; triggers; and social and environmental factors.

CONCLUSIONS

The rate of smoking in CCS is remarkably high, which may partly be explained by negative attitudes toward and low use of evidence-based treatment as well as multi-level barriers to smoking cessation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effect of Sustained Smoking Cessation Counseling and Provision of Medication vs Shorter-term Counseling and Medication Advice on Smoking Abstinence in Patients Recently Diagnosed With Cancer: A Randomized Clinical Trial

IMPORTANCE

Persistent smoking may cause adverse outcomes among patients with cancer. Many cancer centers have not fully implemented evidence-based tobacco treatment into routine care.

OBJECTIVE

To determine the effectiveness of sustained telephone counseling and medication (intensive treatment) compared with shorter-term telephone counseling and medication advice (standard treatment) to assist patients recently diagnosed with cancer to quit smoking.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded randomized clinical trial was conducted at Massachusetts General Hospital/Dana-Farber/Harvard Cancer Center and Memorial Sloan Kettering Cancer Center. Adults who had smoked 1 cigarette or more within 30 days, spoke English or Spanish, and had recently diagnosed breast, gastrointestinal, genitourinary, gynecological, head and neck, lung, lymphoma, or melanoma cancers were eligible. Enrollment occurred between November 2013 and July 2017; assessments were completed by the end of February 2018.

INTERVENTIONS

Participants randomized to the intensive treatment (n = 153) and the standard treatment (n = 150) received 4 weekly telephone counseling sessions and medication advice. The intensive treatment group also received 4 biweekly and 3 monthly telephone counseling sessions and choice of Food and Drug Administration-approved cessation medication (nicotine replacement therapy, bupropion, or varenicline).

MAIN OUTCOME AND MEASURES

The primary outcome was biochemically confirmed 7-day point prevalence tobacco abstinence at 6-month follow-up. Secondary outcomes were treatment utilization rates.

RESULTS

Among 303 patients who were randomized (mean age, 58.3 years; 170 women [56.1%]), 221 (78.1%) completed the trial. Six-month biochemically confirmed quit rates were 34.5% (n = 51 in the intensive treatment group) vs 21.5% (n = 29 in the standard treatment group) (difference, 13.0% [95% CI, 3.0%-23.3%]; odds ratio, 1.92 [95% CI, 1.13-3.27]; P < .02). The median number of counseling sessions completed was 8 (interquartile range, 4-11) in the intensive treatment group. A total of 97 intensive treatment participants (77.0%) vs 68 standard treatment participants (59.1%) reported cessation medication use (difference, 17.9% [95% CI, 6.3%-29.5%]; odds ratio, 2.31 [95% CI, 1.32-4.04]; P = .003). The most common adverse events in the intensive treatment and standard treatment groups, respectively, were nausea (n = 13 and n = 6), rash (n = 4 and n = 1), hiccups (n = 4 and n = 1), mouth irritation (n = 4 and n = 0), difficulty sleeping (n = 3 and n = 2), and vivid dreams (n = 3 and n = 2).

CONCLUSIONS AND RELEVANCE

Among smokers recently diagnosed with cancer in 2 National Cancer Institute-designated Comprehensive Cancer Centers, sustained counseling and provision of free cessation medication compared with 4-week counseling and medication advice resulted in higher 6-month biochemically confirmed quit rates. However, the generalizability of the study findings is uncertain and requires further research.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01871506.

Leveraging Patient Reported Outcomes Measurement via the Electronic Health Record to Connect Patients with Cancer to Smoking Cessation Treatment

Tobacco use negatively impacts cancer treatment outcomes, yet too few providers actively support their patients in quitting. Barriers to consistently addressing tobacco use and referring to treatment include time constraints and lack of knowledge surrounding treatment options. Patient Reported Outcomes (PRO) measurement is best practice in cancer care and has potential to help address these barriers to tobacco cessation treatment. This descriptive program evaluation study reports preliminary results following implementation of a novel automated PRO tobacco use screener and referral system via the electronic health record (EHR) patient portal (MyChart) that was developed and implemented as a part of a population-based tobacco treatment program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Between 25 June 2019 and 6 April 2020, 4589 unique patients completed the screener and 164 (3.6%) unique patients screened positive for recent (past month) cigarette smoking. All patients who screened positive were automatically referred to a smoking cessation treatment program integrated within the Lurie Cancer Center, and 71 (49.7%) patients engaged in treatment, as defined by completing at least one behavioral counseling session. Preliminary results indicate that the PRO/MyChart system may improve smoker identification and increase offering of treatment and, despite the "cold call" following a positive screen, may result in a treatment engagement rate that is higher than rates of treatment engagement previously documented in oncology settings. Longer term evaluation with formal statistical testing is needed before drawing conclusions regarding effectiveness, but PRO measurement via the EHR patient portal may serve a potentially important role in a multi-component approach to reaching and engaging cancer patients in comprehensive tobacco cessation treatment.

An Evaluation of the Process and Quality Improvement Measures of the University of Virginia Cancer Center Tobacco Treatment Program

Tobacco use after a cancer diagnosis can increase risk of disease recurrence, increase the likelihood of a second primary cancer, and negatively impact treatment efficacy. The implementation of system-wide comprehensive tobacco cessation in the oncology setting has historically been low, with over half of cancer clinicians reporting that they do not treat or provide a referral to cessation resources. This quality improvement study evaluated the procedures for assessing and documenting tobacco use among cancer survivors and referring current smokers to cessation resources at the University of Virginia Cancer Center. Process mapping revealed 20 gaps across two major domains: electronic health record (EHR), and personnel barriers. The top identified priority was inconsistent documentation of tobacco use status as it impacted several downstream gaps. Eleven of the 20 gaps were deemed a high priority, and all were addressed during the implementation of the resulting Tobacco Treatment Program. Prioritized gaps were addressed using a combination of provider training, modifications to clinical workflow, and EHR modifications. Since implementation of solutions, the number of unique survivors receiving cessation treatment has increased from 284 survivors receiving cessation support during Year 1 of the initiative to 487 in Year 3. The resulting Tobacco Treatment Program provides a systematic, personalized, and sustainable comprehensive cessation program that optimizes the multifaceted workflow of the Cancer Center and has the potential to reduce tobacco use in a population most in need of cessation support.

The Emergence of a Sustainable Tobacco Treatment Program across the Cancer Care Continuum: A Systems Approach for Implementation at the University of California Davis Comprehensive Cancer Center

Tobacco treatment is increasingly recognized as important to cancer care, but few cancer centers have implemented sustainable tobacco treatment programs. The University of California Davis Comprehensive Cancer Center (UCD CCC) was funded to integrate tobacco treatment into cancer care. Lessons learned from the UCD CCC are illustrated across a systems framework with the Cancer Care Continuum and by applying constructs from the Consolidated Framework for Implementation Research. Findings demonstrate different motivational drivers for the cancer center and the broader health system. Implementation readiness across the domains of the Cancer Care Continuum with clinical entities was more mature in the Prevention domain, but Screening, Diagnosis, Treatment, and Survivorship domains demonstrated less implementation readiness despite leadership engagement. Over a two-year implementation process, the UCD CCC focused on enhancing information and knowledge sharing within the treatment domain with the support of the cancer committee infrastructure, while identifying available resources and adapting workflows for various cancer care service lines. The UCD CCC findings, while it may not be generalizable to all cancer centers, demonstrate the application of conceptual frameworks to accelerate implementation for a sustainable tobacco treatment program. Key common elements that may be shared across oncology settings include a state quitline for an adaptable intervention, cancer committees for outer/inner setting infrastructure, tobacco quality metrics for data reporting, and non-physician staff for integrated services.

Patient-Reported Outcomes From Patients Receiving Immunotherapy or Chemoimmunotherapy for Metastatic Non-Small-Cell Lung Cancer in Clinical Practice

INTRODUCTION

Immunotherapy and chemoimmunotherapy clinical trials for metastatic non-small-cell lung cancer (mNSCLC) have generally excluded patients with poor performance status (PS) and have utilized patient-reported measures that could miss some symptoms associated with immunotherapy. The goals of this study were to describe quality of life and symptom burden among mNSCLC patients receiving immunotherapy in clinical practice, and to examine burden by Eastern Cooperative Oncology Group performance status (ECOG PS) and age.

PATIENTS AND METHODS

Between 2017 and 2018, mNSCLC patients receiving immuno/chemoimmunotherapy at an academic medical center completed the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ-C30) and the National Cancer Institute Patient Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Univariate and bivariate analyses described EORTC-QLQ-C30 subscales and the proportion reporting at least moderate PRO-CTCAE symptoms, and compared scores by ECOG PS (0/1 vs. 2/3) and age (< 70 vs. ≥ 70 years).

RESULTS

Sixty patients (60% female; 75% < 70 years old; 68% ECOG PS 0/1; 57% receiving single-agent immunotherapy) participated. The mean EORTC-QLQ-C30 global health score was 62.6; EORTC symptoms were highest for fatigue, insomnia, dyspnea, and financial concerns (all > 30). Global health and pain were worse in ECOG PS 2/3 patients. For PRO-CTCAE, 20% to 40% reported at least moderate gastrointestinal, respiratory, dermatologic, arthralgia, or myalgia symptoms. The PRO-CTCAE pain score was higher among ECOG PS 2/3 patients.

CONCLUSION

In clinical practice, global health was largely comparable to published clinical trials, but PRO-CTCAE items indicated a higher symptom prevalence. Closer monitoring of symptoms is warranted in ECOG PS 2/3 patients.

Item Development and Performance of Tobacco Product and Regulation Perception Items for the Health Information National Trends Survey

INTRODUCTION

Emerging tobacco products have become increasingly popular, and the US Food and Drug Administration extended its authority to all products meeting the definition of a tobacco product in 2016. These changes may lead to shifts in public perceptions about tobacco products and regulation, and national surveys are attempting to assess these perceptions at the population level. This article describes the item development and cognitive interviewing of the tobacco product and regulation perception items included in two tobacco-focused cycles of the Health Information National Trends Survey (HINTS-FDA), referred to as HINTS-FDA.

METHODS

Cognitive interviewing was used to investigate how respondents comprehended and responded to tobacco product and regulation perception items. Adult participants (n = 20) were selected purposively to oversample current tobacco users and were interviewed in two iterative rounds. Weighted descriptive statistics from the fielded HINTS-FDA surveys (N = 5474) were also calculated.

RESULTS

Items were generally interpreted as intended, and participants meaningfully discriminated between tobacco products when assessing addiction perceptions. Response selection issues involved inconsistent reporting among participants with little knowledge or ambivalent opinions about either government regulation or tobacco products and ingredients, which resolved when a "don't know" response option was included in the survey. The fielded survey found that a non-negligible proportion of the population do not have clear perceptions of emerging tobacco products or government regulation.

CONCLUSIONS

A "don't know" response option is helpful for items assessing many emerging tobacco products but presents several analytic challenges that should be carefully considered. Multiple items assessing specific tobacco product and regulation perception items are warranted in future surveys.

IMPLICATIONS

The findings from this study can serve as a foundation for future surveys that assess constructs related to emerging tobacco products, harm perceptions across multiple tobacco products, and tobacco-related government regulatory activities. The data provide unique insight into item-specific motivation for selecting a "don't know" response option for tobacco survey items.

Mitigating the adverse health effects and costs associated with smoking after a cancer diagnosis

Smoking after a cancer diagnosis causes adverse outcomes and is associated with substantial additional treatment cost. Mitigation of the adverse effects of smoking require active commitment from health systems, providers, and patients. Three areas of mitigation are discussed: (I) smoking cessation after a cancer diagnosis to improve cancer treatment outcomes; (II) identifying optimal cancer treatment strategies for patients who smoke at the time of diagnosis; and (III) how health systems can prioritize the effect modification caused by smoking. As innovation continues for healthcare delivery, priority should be placed on interventions that reduce the effect modification and associated costs caused by continued smoking after a cancer diagnosis.

Association Between Head and Neck Squamous Cell Carcinoma Survival, Smoking at Diagnosis, and Marital Status

Importance

While the adverse association between smoking and head and neck squamous cell carcinoma (HNSCC) survival has been well described, there are also inconclusive studies and those that report no significant changes in HNSCC survival and overall mortality due to smoking. There is also a lack of studies investigating the association of marital status on smoking status at diagnosis for patients with HNSCC.

Objective

To examine the association between patient smoking status at HNSCC diagnosis and survival and the association between marital status and smoking in these patients.

Design, Setting, and Participants

This retrospective cohort study was conducted by querying the Saint Louis University Hospital Tumor Registry for adults with a diagnosis of HNSCC and treated at the university academic medical center between 1997 and 2012; 463 confirmed cases were analyzed.

Main Outcomes and Measures

Cox proportional hazards regression analysis was used to evaluate association of survival with smoking status at diagnosis and covariates. A multivariate logistic regression model was used to assess whether marital status was associated with smoking at diagnosis adjusting for covariates.

Results

Of the 463 total patients (338 men, 125 women), 92 (19.9%) were aged 18 to 49 years; 233 (50.3%) were aged 50 to 65 years; and 138 (29.8%) were older than 65 years. Overall, 56.2% of patients were smokers at diagnosis (n = 260); 49.6% were married (n = 228); and the mortality rate was 54.9% (254 died). A majority of patients were white (81.0%; n = 375). Smokers at diagnosis were more likely to be younger (ie, <65 years), unmarried, and to drink alcohol. We found a statistically significant difference in median survival time between smokers (89 months; 95% CI, 65-123 months) and nonsmokers at diagnosis (208 months; 95% CI, 129-235 months). In the adjusted Cox proportional hazards model, patients who were smokers at diagnosis were almost twice as likely to die during the study period as nonsmokers (hazard ratio, 1.98; 95% CI, 1.42-2.77). In the multivariate logistic regression analysis, unmarried patients were 76% more likely to use tobacco than married patients (adjusted odds ratio, 1.76; 95% CI, 1.08-2.84).

Conclusions and Relevance

Smokers were almost twice as likely as nonsmokers to die during the study period. We also found that those who were married were less likely to be smokers at diagnosis. Our study suggests that individualized cancer care should incorporate social support and management of cancer risk behaviors.

Research Priorities, Measures, and Recommendations for Assessment of Tobacco Use in Clinical Cancer Research

There is strong evidence that cigarette smoking causes adverse outcomes in people with cancer. However, more research is needed regarding those effects and the effects of alternative tobacco products and of secondhand smoke, the effects of cessation (before diagnosis, during treatment, or during survivorship), the biologic mechanisms, and optimal strategies for tobacco dependence treatment in oncology. Fundamentally, tobacco is an important source of variation in clinical treatment trials. Nevertheless, tobacco use assessment has not been uniform in clinical trials. Progress has been impeded by a lack of consensus regarding tobacco use assessment suitable for cancer patients. The NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified priority research areas and developed recommendations for assessment items and timing of assessment in cancer research. A cognitive interview study was conducted with 30 cancer patients at the NIH Clinical Center to evaluate and improve the measurement items. The resulting Cancer Patient Tobacco Use Questionnaire (C-TUQ) includes "Core" items for minimal assessment of tobacco use at initial and follow-up time points, and an "Extension" set. Domains include the following: cigarette and other tobacco use status, intensity, and past use; use relative to cancer diagnosis and treatment; cessation approaches and history; and secondhand smoke exposure. The Task Force recommends that assessment occur at study entry and, at a minimum, at the end of protocol therapy in clinical trials. Broad adoption of the recommended measures and timing protocol, and pursuit of the recommended research priorities, will help us to achieve a clearer understanding of the significance of tobacco use and cessation for cancer patients.