Availability of smoking prevention and cessation services for childhood cancer survivors

Smoking behavior among adult childhood cancer survivors: what are we missing?

PURPOSE

Childhood cancer survivors are a growing population at increased risk for smoking-related health complications. This study compared smoking prevalence, age at smoking initiation, and time trend of smoking prevalence from 1997 to 2010 between adult survivors of childhood cancer and adults without a cancer history (controls) and identified predictors of smoking among these survivors.

METHODS

Data were pooled from the 1997-2010 National Health Interview Survey (survivors, n = 1438; controls, n = 383,805). Smoking prevalence by age group was calculated using weighted least square regression analysis and weighted linear regression of prevalence on year for trend analysis. Logistic regression analyses adjusting for sample weights and design effects were performed to identify predictors of smoking among survivors.

RESULTS

Compared to controls, survivors were significantly more likely to be younger, female, non-Hispanic White, unemployed, with lower income, and to weigh less and smoke more. Survivors initiated smoking earlier than controls. Smoking prevalence among survivors peaked at age 30 and 40 years old, compared to age 25 years in controls. Smoking prevalence decreased consistently from 1997 to 2010 among controls, with larger significant declines in survivors that were subject to more year-to-year variability. Compared to nonsmoking survivors, those who smoke were significantly more likely to be non-Hispanic White, young, uninsured, poor, to have a high school education or less, and to report drinking alcohol.

CONCLUSION

Smoking in adult survivors of childhood cancer continues as a persistent risk factor across socioeconomic groups.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted and tailored smoking cessation/prevention interventions for these survivors are needed.

Needs and Lifestyle Challenges of Adolescents and Young Adults With Cancer: Summary of an Institute of Medicine and Livestrong Foundation Workshop

BACKGROUND

Among adolescents and young adults (AYAs) in the United States, cancer is the leading cause of disease-related death. AYA survivors face numerous short- and long-term health and psychosocial issues, as well as increased risk for behavioral and lifestyle challenges, including poor diet, low physical activity (PA), and substance abuse. Many of these behaviors are modifiable, but gaps in care serve as barriers for AYA survivors.

OBJECTIVES

The purpose of this article is to (a) raise awareness of AYAs' increased risk for poor diet, low PA, and substance abuse; (b) examine previous interventions addressing these issues; and (c) provide recommendations for future directions.

METHODS

This article summarizes a workshop coordinated by the Institute of Medicine and the Livestrong Foundation to address AYA survivors' needs and ways to enhance their quality of care.

FINDINGS

Oncology nurses can promote the inclusion of lifestyle behaviors in survivorship care plans of AYA patients and serve as a valuable resource in improving AYA care on a larger scale. In addition, oncology nurse researchers may offer greater understanding of AYA patients' and survivors' needs and best practices by conducting much-needed research with this understudied population.

Partnership for health-2, a web-based versus print smoking cessation intervention for childhood and young adult cancer survivors: randomized comparative effectiveness study

BACKGROUND

Smoking among cancer survivors increases the risk of late effects and second cancers. This article reports on Partnership for Health-2 (PFH-2)-an effort to develop an effective and scalable version of Partnership for Health (PFH), which was a previously tested peer-delivered telephone counseling program that doubled smoking cessation rates among childhood cancer survivors who smoke.

OBJECTIVE

This paper presents results from a randomized controlled trial evaluating the effectiveness of PFH-2 in targeted and tailored Web-based versus print formats. The overall goal was to determine whether the intervention outcomes in these self-guided scalable formats approximate what was found in a more intensive telephone counseling program.

METHODS

This study was a randomized controlled trial with a 15-month follow-up that included 374 smokers who were survivors of childhood or young adult cancers, recruited from five survivorship clinics. Participants were randomly assigned to a Web-based or print format of the PFH intervention; all had access to free pharmacotherapy. The website was designed to provide new content at each log-on, and a peer counselor moderated a forum/chat feature. The primary outcome was smoking status at 15 months post randomization.

RESULTS

In total, 58.3% (77/132) of Web participants logged on at least once (mean visits 3.25). Using multiple imputation methods for missing data, there were similar rates of cessation in the two arms (print: 20/128, 15.6%; Web: 33/201, 6.4%), and no differences in quit attempts or readiness to quit. The quit rates were equivalent to those found in our previous telephone counseling intervention. There were high rates of satisfaction with both of the PFH-2 interventions.

CONCLUSIONS

The print and Web formats yielded equivalent levels of success to those found with our telephone-delivered intervention and are comparable to other Internet treatment studies. This study provides important options for survivorship programs that may not have resources for interpersonal forms of cessation counseling. Efforts to increase patient use of the interventions may result in higher cessation rates.

Treatment-related cardiotoxicity in survivors of childhood cancer

Treatment advances and higher participation rates in clinical trials have rapidly increased the number of survivors of childhood cancer. However, chemotherapy and radiation treatments are cardiotoxic and can cause cardiomyopathy, conduction defects, myocardial infarction, hypertension, stroke, pulmonary oedema, dyspnoea and exercise intolerance later in life. These cardiotoxic effects are often progressive and irreversible, emphasizing a need for effective prevention and treatment to reduce or avoid cardiotoxicity. Medical interventions, such as angiotensin-converting enzyme inhibitors, β-blockers, and growth hormone therapy, might be used to treat cardiotoxicity in childhood cancer survivors. Preventative strategies should include the use of dexrazoxane, which provides cardioprotection without reducing the oncological efficacy of doxorubicin chemotherapy; less-toxic anthracycline derivatives and the use of antioxidant nutritional supplements might also be beneficial. Continuous-infusion doxorubicin provides no benefit over bolus infusion in children. Identifying patient-related (for example, obesity and hypertension) and drug-related (for example, cumulative dose) risk factors for cardiotoxicity could help tailor treatments to individual patients. However, all survivors of childhood cancer are at increased risk of cardiotoxicity, suggesting that survivor screening recommendations for assessment of global risk of premature cardiovascular disease should apply to all survivors. Optimal, evidence-based monitoring strategies and multiagent preventative treatments still need to be identified.

Smokeless and dual tobacco use among males surviving childhood cancer: a report from the Childhood Cancer Survivor Study

Cancer survivors experience treatment-related complications that can be exacerbated by tobacco use. This study reports the prevalence of smokeless and dual tobacco use, compares these rates to the U.S. population, and examines tobacco risk factors among males surviving childhood cancer. Data from the Childhood Cancer Survivor Study (CCSS) 2007 survey were used (N = 3378). Standardized incidence ratios (SIR) were obtained by comparing CCSS data with the National Survey on Drug Use and Health. Logistic regression was used to evaluate associations between risk factors and tobacco use. Among male survivors, 8.3% and 2.3% were current smokeless tobacco and dual tobacco users, respectively. Survivors were less likely than population males to report smokeless tobacco [SIR = 0.64; 95% confidence interval (CI), 0.57-0.72) or dual tobacco (SIR = 0.37; CI, 0.29-0.46) use; however, non-White survivors aged 35 to 49 years were more likely to use smokeless tobacco (SIR = 2.32; CI, 1.27-3.90). Smokeless tobacco use was associated (P < 0.05) with younger age at diagnosis, lower education, being married or divorced/separated, and not living in the Northeastern United State, whereas history of cardiovascular- and/or pulmonary-toxic treatment was protective. Dual tobacco use was associated with younger age at diagnosis, lower education, divorce/separation, and high psychologic distress. Having active heart or circulatory conditions was protective. Although smokeless tobacco/dual tobacco use is generally low among childhood cancer survivors, these findings suggest that tobacco use screening should be expanded to include smokeless tobacco use, and that smokeless tobacco-specific education and cessation interventions should be provided to users. Screening and intervening for smokeless tobacco/dual tobacco use in childhood cancer survivors will reduce tobacco-related morbidity and mortality.

The effect of cigarette smoking on cancer treatment-related side effects

BACKGROUND

Cigarette smoking has long been implicated in cancer development and survival. However, few studies have investigated the impact of smoking on symptom burden in cancer survivors during treatment and at survivorship stage. This study examines the influence of cigarette smoking on side effects among 947 cancer patients during and 6 months following treatment.

METHODS

Patients diagnosed with cancer and scheduled to receive chemotherapy and/or radiation therapy reported on current smoking status (yes, no) and total symptom burden [the sum of 12 common symptoms (fatigue, hair loss, memory, nausea, depression, sleep, pain, concentration, hot flashes, weight loss, skin problems, and dyspnea) scored on an 11-point scale ranging from 0 = "not present" to 10 = "as bad as you can imagine"] during treatment and at 6-month follow-up. The adjusted mean total symptom burden by smoking status was determined by analysis of covariance controlling for age, gender, race, education, occupation, treatment, cancer site, and Karnofsky performance score.

RESULTS

During treatment, smokers (S) had a significantly higher total symptom burden than nonsmokers (NS) (S = 46.3 vs. NS = 41.2; p < 0.05). At 6-month follow-up, smokers continued to report a higher total symptom burden than nonsmokers (S = 27.7 vs. NS = 21.9; p < 0.05). Participants who quit smoking before treatment levels had a total symptom burden similar to nonsmokers.

CONCLUSION

Smoking was associated with an increased symptom burden during and following treatments for cancer. Targeted cessation efforts for smokers to decrease symptom burden may limit the likelihood of treatment interruptions and increase quality of life following treatment.

Disseminating a smoking cessation intervention to childhood and young adult cancer survivors: baseline characteristics and study design of the partnership for health-2 study

BACKGROUND

Partnership for Health-2 (PFH-2) is a web-based version of Partnership for Health, an evidence-based smoking cessation intervention for childhood cancer survivors. This paper describes the PFH-2 intervention and baseline data collection.

METHODS

374 childhood and young adult cancer survivors were recruited from five cancer centers and participated in the baseline assessment. At baseline, participants completed measures of their smoking behavior, self-efficacy and stage of change for quitting smoking as well as psychological and environmental factors that could impact their smoking behavior.

RESULTS

At baseline, 93% of survivors smoked in the past seven days; however, 89% smoked a pack or less during this period. Forty-seven percent were nicotine dependent, and 55% had made at least one quit attempt in the previous year. Twenty-two percent of survivors were in contemplation for quitting smoking; of those 45% were somewhat or very confident that they could quit within six months. Sixty-three percent were in preparation for quitting smoking; however, they had relatively low levels of confidence that they could quit smoking in the next month. In multivariate analyses, stage of change, self-efficacy, social support for smoking cessation, smoking policy at work and home, fear of cancer recurrence, perceived vulnerability, depression, BMI, and contact with the healthcare system were associated with survivors' smoking behavior.

DISCUSSIONS/CONCLUSIONS

A large proportion of the sample was nicotine dependent, yet motivated to quit. Individual- interpersonal- and environmental-level factors were associated with survivors' smoking behavior. Smoking is particularly dangerous for childhood and young adult cancer survivors. This population may benefit from a smoking cessation intervention designed to build self-efficacy and address other known predictors of smoking behavior.

Long-term smoking cessation outcomes among childhood cancer survivors in the Partnership for Health Study

PURPOSE

Partnership for Health (PFH) was found to increase smoking cessation among smokers in the Childhood Cancer Survivors Study (CCSS) at the 8- and 12-month postbaseline follow-up. This report provides outcomes at 2 to 6 years postbaseline; the primary outcome is a four-category smoking status variable (quit at all follow-ups, quit at final follow-up only, smoker at all follow-ups, and smoker at final follow-up only); quit attempts among those who reported smoking at the final follow-up is a secondary outcome.

METHODS

PFH was a randomized control trial with two conditions, peer phone counseling (PC) and self-help (SH), that involved smokers (n = 796) enrolled in the CCSS cohort.

RESULTS

Long-term quit rates were higher in PC versus SH participants. Long-term smoking cessation outcomes were lower among those who were nicotine dependent, of lower educational levels, and among men, and were higher among those who used nicotine replacement therapy and who had higher levels of situational self-efficacy. There were no significant differences in relapse rates between conditions or in quit attempts among continued smokers.

CONCLUSION

Cessation rates continue to be significantly higher among participants in the PC condition versus SH, although the differences were not large. This article highlights differences in long-term engagement with smoking cessation among those who received the intervention.

Issues related to implementing a smoking cessation clinical trial for cancer patients

Given high rates of smoking among cancer patients, smoking cessation treatment is crucial; yet limited data exist to guide integration of such trials into the oncologic context. In order to determine the feasibility of conducting smoking cessation clinical trials with cancer patients, screening and baseline data from a large randomized placebo-controlled pharmacotherapy trial were analyzed. Descriptive statistics and regression analyses were used to compare enrollees to decliners, describe program enrollees, and assess correlates of confidence in quitting smoking. Out of 14,514 screened patients, 263 (<2%) were eligible; 43 (16%) refused enrollment. Among the eligible patients, 220 (84%) enrolled. Enrollment barriers included smoking rate, medical history/contraindicated medication, lack of interest, and language. Compared to enrollees, decliners were more likely to have advanced cancer. The trial enrolled a sample of 67 (>30%) African Americans; participants had extensive smoking histories; many were highly nicotine dependent; and participants consumed about seven alcoholic beverages/week on average. Head and neck and breast cancer were the most common tumors. About 52 (25%) reported depressive symptoms. A higher level of confidence to quit smoking was related to lower depression and lower tumor stage. Integrating a smoking cessation clinical trial into the oncologic setting is challenging, yet feasible. Recruitment strategies are needed for patients with advanced disease and specific cancers. Once enrolled, addressing participant's depressive symptoms is critical for promoting cessation.

Promoting a healthy lifestyle among cancer survivors

With improving longevity, the late-occurring adverse effects of cancer and its treatment are becoming increasingly apparent. As in other clinical populations, healthy lifestyle behaviors encompassing weight management, a healthy diet, regular exercise, and smoking cessation have the potential to reduce morbidity and mortality significantly in cancer survivors. This article addresses the strength of evidence for recommendations in areas of weight management, diet, exercise, and smoking cessation; and the current evidence examining the efficacy of various intervention approaches to promote health behavior changes among adult cancer survivors.