Effect of a Smoking and Alcohol Cessation Intervention Initiated Shortly Before Radical Cystectomy-the STOP-OP Study: A Randomised Clinical Trial

Identification of Alcohol Use Prior to Major Cancer Surgery: Timeline Follow Back Interview Compared to Four Other Markers

BACKGROUND

The postoperative complication rate is 30-64% among patients undergoing muscle-invasive and recurrent high-risk non-muscle-invasive bladder cancer surgery. Preoperative risky alcohol use increases the risk. The aim was to evaluate the accuracy of markers for identifying preoperative risky alcohol.

METHODS

Diagnostic test sub-study of a randomized controlled trial (STOP-OP trial), based on a cohort of 94 patients scheduled for major bladder cancer surgery. Identification of risky alcohol use using Timeline Follow Back interviews (TLFB) were compared to the AUDIT-C questionnaire and three biomarkers: carbohydrate-deficient transferrin in plasma (P-CDT), phosphatidyl-ethanol in blood (B-PEth), and ethyl glucuronide in urine (U-EtG).

RESULTS

The correlation between TLFB and AUDIT-C was strong (ρ = 0.75), while it was moderate between TLFB and the biomarkers (ρ = 0.55-0.65). Overall, sensitivity ranged from 56 to 82% and specificity from 38 to 100%. B-PEth showed the lowest sensitivity at 56%, but the highest specificity of 100%. All tests had high positive predictive values (79-100%), but low negative predictive values (42-55%).

CONCLUSIONS

Despite high positive predictive values, negative predictive values were weak compared to TLFB. For now, TLFB interviews seem preferable for preoperative identification of risky alcohol use.

Association between psychosocial factors and co-morbid cigarette smoking and alcohol use in a population experiencing homelessness

The prevalence of combustible cigarette smoking in populations experiencing homelessness in the United States is five times that of the general population. The psychosocial well-being of persons who smoke and experience homelessness is poorer if such persons also use alcohol heavily. The PTQ2 study was a randomized clinical trial among persons experiencing homelessness who were also current smokers and heavy alcohol consumers. Secondary data analysis of the PTQ2 baseline data was conducted to examine associations among psychosocial variables (anxiety, depression, hopelessness, social network size), heaviness of smoking (cigarettes/day) and alcohol consumption (drinking days/month), and duration and frequency of homelessness. Among the 420 participants, the majority were male (75%), black (70%) and non-Hispanic (94%) with a mean age of 46.6 years (SD = 11.6).  Bivariate analyses show that heaviness of smoking was positively correlated with social network size (r = 0.16, p = .001). Heaviness of drinking was positively correlated with the MINI anxiety score (r = 0.13, p = .009) and marijuana use (median total number of drinks in past 30 days among those who used marijuana in past 30 days vs. did not use: 50 vs. 24, p < .0001), and associated with frequency of homelessness (median total number of drinks in past 30 days among those experiencing homelessness once vs. >1 time: 30 vs. 44, p = .022). The findings highlight the psychosocial factors that warrant consideration when addressing heavy smoking and alcohol consumption in persons experiencing homelessness.

Preoperative smoking and robot-assisted radical cystectomy outcomes & complications in multicenter KORARC database

To investigate the influence of preoperative smoking history on the survival outcomes and complications in a cohort from a large multicenter database. Many patients who undergo radical cystectomy (RC) have a history of smoking; however, the direct association between preoperative smoking history and survival outcomes and complications in patients with muscle-invasive bladder cancer (MIBC) who undergo robot-assisted radical cystectomy (RARC) remains unexplored. We conducted a retrospective analysis using data from 749 patients in the Korean Robot-Assisted Radical Cystectomy Study Group (KORARC) database, with an average follow-up duration of 30.8 months. The cohort was divided into two groups: smokers (n = 351) and non-smokers (n = 398). Propensity score matching was employed to address differences in sample size and baseline demographics between the two groups (n = 274, each). Comparative analyses included assessments of oncological outcomes and complications. After matching, smoking did not significantly affect the overall complication rate (p = 0.121). Preoperative smoking did not significantly increase the occurrence of complications based on complication type (p = 0.322), nor did it increase the readmission rate (p = 0.076). There were no perioperative death in either group. Furthermore, preoperative smoking history showed no significant impact on overall survival (OS) [hazard ratio (HR) = 0.87, interquartile range (IQR): 0.54-1.42; p = 0.589] and recurrence-free survival (RFS) (HR = 1.12, IQR: 0.83-1.53; p = 0.458) following RARC for MIBC. The extent of preoperative smoking (≤ 10, 10-30, and ≥ 30 pack-years) had no significant influence on OS and RFS in any of the categories (all p > 0.05). Preoperative smoking history did not significantly affect OS, RFS, or complications in patients with MIBC undergoing RARC.

Is It Worth the Sweat? Prehabilitation in Uro-oncology: A Mini Review

In several surgical specialities, exercise as part of a prehabilitation program enhances recovery. However, for uro-oncological patients, evidence up to 2020 did not demonstrate significant benefits in terms of postoperative complications or hospital length of stay (LOS). We reviewed the literature from 2020 to 2023 and screened 205 reports, of which four full texts were included. Two retrospective cohort studies, despite having potential confounding risks, indicated that preoperative exercise might reduce LOS. One of these studies also suggested a lower likelihood of complications. Present evidence hints at the potential benefits of embedding exercise in prehabilitation for uro-oncological patients, particularly for short-term functional results. However, evidence on a direct effect on postoperative complications and LOS is still inconclusive. Future research should prioritise identification of specific exercises (eg, anaerobic vs aerobic, strength training, endurance, or respiratory exercises) that yield the most cost-effective benefits. PATIENT SUMMARY: Recent studies suggest that exercising before surgery might help people with urological cancers to improve their short-term fitness. More research is needed to see if exercise before surgery shortens hospital stays or reduces complications.

The effect of a smoking cessation program for patients in cancer treatment: a quasi-experimental intervention study

BACKGROUND

Compared to non-smokers, smokers have reduced effects of cancer treatment, and increased risk of treatment-related toxicity. Quitting smoking can improve treatment effects and reduce side effects. This study reports on the potential impact of a smoking cessation program on smoking cessation rates among patients in cancer treatment.

MATERIAL AND METHODS

Cancer patients 18 years and older who smoked, with survival prognosis ≥12 months, not suffering dementia or other mental illness, and who were referred to cancer treatment at six Norwegian hospitals were invited to participate. The study took place from 2017 to 2020 and used a pre-test-posttest non-equivalent control group design. The intervention group received structured smoking cessation guidance based on Motivational Interviewing combined with cost-free nicotine replacement products, while the control group received standard smoking cessation treatment. Self-reported smoking status were registered at baseline and at 6 months' follow up.

RESULTS

76% of patients smoked at baseline and 44% at follow-up in the intervention group, correspondingly 72% and 49% in the control group. In an analysis of differences in within-person change, the reduction in the intervention group was 13 percentage points larger (95% CI = (0.25, -0.005), p = 0.041). Adjusting for gender, age, education, labour market participation and partnership status did not attenuate the estimated effect (18 percentage point difference, 95% CI = (-0.346, -0.016), p = 0.032). Demographic factors and dropout rate differed somewhat between the groups with a higher dropout rate in the intervention group, 54% vs. 51%, respectively).

CONCLUSION

Offering a structured smoking cessation program based on Motivational Interviewing and cost-free nicotine replacement products to cancer patients can increase cessation rates in comparison to standard smoking cessation care.

Peri-operative tobacco cessation interventions: a systematic review and meta-analysis

Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20-1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29-2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.

Recommendations on the use of prehabilitation, i.e. comprehensive preparation of the patient for surgery

Prehabilitation is a comprehensive preparation of a patient for primarily surgical treatments. Its aim is to improve the patient'sgeneral condition so as to reduce the risk of complications and ensure the fastest possible recovery to full health. Thebasic components of prehabilitation include: improvement of nutritional status, appropriate exercises to improve functioning,psychological support, and help in eliminating addictions. Other important aspects of prehabilitation are: increasinghemoglobin levels in patients with anemia, achieving good glycemic control in patients with diabetes, treatment or stabilizationof any concurrent disorders, or specialist treatment associated with a specific procedure (endoprostheses, ostomyprocedure). This article organizes and outlines the indications for prehabilitation, its scope, duration, and the method to conductit. Experts of various specialties related to prehabilitation agree that it should be an element of surgery preparationwhenever possible, especially in patients with co-existing medical conditions who have been qualified for major procedures.Prehabilitation should be carried out by interdisciplinary teams, including family physicians and various specialists in thetreatment of comorbidities. Prehabilitation requires urgent systemic and reimbursement solutions.

Adverse Surgical Outcomes Linked to Co-occurring Smoking and Risky Alcohol Use Among General Surgery Patients

OBJECTIVE

To assess associations between co-occurring preoperative smoking and risky alcohol use on the likelihood of adverse surgical outcomes.

BACKGROUND

Risky alcohol use and smoking are the known surgical risk factors with a high co-occurrence and additive adverse effects on multiple organ systems that impact surgical health, yet no research has evaluated the impact of co-occurrence on surgical outcomes.

METHODS

This investigation analyzed 200,816 patients from the Michigan Surgical Quality Collaborative database between July 1, 2012, to December 31, 2018. Patients were classified based on past year risky alcohol use (>2 drink/day) and cigarette smoking into 4 groups: (1) risky alcohol and smoking, (2) risky alcohol only, (3) smoking only, and (4) no risky alcohol/smoking. We fitted logistic regression models, applying propensity score weights incorporating demographic, clinical, and surgical factors to assess associations between alcohol and smoking and 30-day postoperative outcomes; surgical complications, readmission, reoperation, and emergency department (ED) visits.

RESULTS

Risky alcohol and smoking, risky alcohol only, and smoking only were reported by 2852 (1.4%), 2840 (1.4%), and 44,042 (22%) patients, respectively. Relative to all other groups, the alcohol and smoking group had greater odds of surgical complications, readmission, and reoperation. Relative to the no alcohol and smoking group, the alcohol only group higher odds of reoperation and smoking only group had higher odds of emergency department visits.

CONCLUSIONS

The combination of smoking and risky drinking conferred the highest likelihood of complications, readmission, and reoperation before surgery. Co-occurring alcohol and smoking at the time of surgery warrants special attention as a patient risk factor and deserves additional research.

Global trends in the epidemiology of bladder cancer: challenges for public health and clinical practice

Bladder cancer is among the ten most common cancers globally, causes considerable morbidity and mortality and is, therefore, a substantial burden for health-care systems. The incidence of bladder cancer is affected by demographic trends, most notably population growth and ageing, as well as exposure to risk factors, especially tobacco smoking. Consequently, the incidence has not been stable throughout the world over time, nor will it be in the near future. Further primary prevention efforts are of the utmost importance to reduce the medical and financial burden of bladder cancer on populations and health-care systems. Simultaneously, less-invasive and lower-cost approaches for the diagnosis of both primary and recurrent bladder cancers are required to address challenges posed by the increasing shortage of health-care professionals and limited financial resources worldwide. In this regard, urinary biomarkers have demonstrated promising diagnostic accuracy and efficiency. Awareness of the risk factors and symptoms of bladder cancer should also be increased in society, particularly among health-care professionals and high-risk groups. Studies investigating the associations between lifestyle factors and bladder cancer outcomes are scarce and should be a research priority. In this Review, we outline global trends in bladder cancer incidence and mortality, and discuss the main risk factors influencing bladder cancer occurrence and outcomes. We then discuss the implications, challenges and opportunities of these epidemiological trends for public health and clinical practice.

Intervention training of urology healthcare staff to counsel acute care inpatients on smoking cessation: An evaluation study

AIM

To evaluate the differences, following intervention training, in the knowledge, attitudes, role perception, self-capacity and intention of urology staff to counsel inpatients on smoking cessation.

DESIGN

A descriptive evaluation study of intervention training in counselling on smoking cessation. The study was designed following guidance by the Medical Research Council.

METHODS

The evaluation was based on a closed-end questionnaire with four time-point measurements from May 2018-December 2019 (N = 29 at each time-point). A repeated measure within-subjects ANOVA was conducted to explore the variance in participants' attitudes, role perception, self-capacity and intention to counsel patients regarding smoking cessation. Eta squared and Bonferroni post hoc tests were used to interpret the results.

RESULTS

No change was observed in the research variables after theoretical science-based learning of the smoking hazards and the benefits of cessation. A statistically significant difference was found following procedural knowledge based on training, practical experience and skill development.

Future Perspectives on Prehabilitation Interventions in Cancer Surgery

OBJECTIVE

This article provides a map of key knowledge gaps regarding the evidence supporting prehabilitation and its integration with enhanced recovery after surgery (ERAS) programs. Filling this lack of knowledge with future research will further establish the effectiveness of prehabilitation.

DATA SOURCES

These are electronic databases including PubMed and CINAHL.

CONCLUSION

Future efforts must embrace the elderly frail or cognitively impaired patient with specific needs to further promote restoration of postoperative function throughout the surgical pathway. Prehabilitation should be coupled and integrated within the existent concept of the ERAS framework, to facilitate the continuous evolution of screening, assessment, and optimization of high-risk surgical patients who are at risk of not being restored to physical and psychological function after surgery, including independence.

IMPLICATIONS FOR NURSING PRACTICE

In the future, the ERAS nurse will be an essential figure of the prehabilitation program, proactively coordinating the assessment, optimization, and adjustment of perioperative comorbidity and guiding the rehabilitation process to improve patients' outcomes. These skills and characteristics will be required to provide optimal nursing care in the context of an integrated prehabilitation ERAS pathway.

Prehabilitation to Improve Outcomes of Patients with Gynaecological Cancer: A New Window of Opportunity?

Simple Summary

Surgery is an important mainstay in the treatment of gynaecological cancers but is associated with operative complications, especially for those with poor physical and mental health. Prehabilitation is a new and upcoming strategy to optimise patients’ functional capacity, nutritional status and psychosocial wellbeing in order to reduce complications and enhance recovery. In this review, we assessed the evidence on prehabilitation programmes for patients with gynaecological cancer. The limited evidence shows that prehabilitation may reduce length of hospital stay for ovarian cancer patients, and may result in significant weight loss in patients with endometrial and cervical cancer. Comparative prospective studies are required to determine the effectiveness of prehabilitation on reducing operative complications and improving quality of life, and to further specify the content of such a programme for patients with gynaecological cancer.

Abstract

The literature evaluating the effect of prehabilitation programmes on postoperative outcomes and quality of life of patients with gynaecological cancer undergoing surgery was reviewed. Databases including Pubmed, Medline, EMBASE (Ovid) and PsycINFO were systematically searched to identify studies evaluating the effect of prehabilitation programmes on patients with gynaecological cancer. Both unimodal and multimodal prehabilitation programmes were included encompassing physical exercise and nutritional and psychological support. Primary outcomes were surgical complications and quality of life. Secondary outcomes were anthropometric changes and adherence to the prehabilitation programme. Seven studies fulfilled the inclusion criteria, comprising 580 patients. Included studies were nonrandomised prospective studies (n = 4), retrospective studies (n = 2) and one case report. Unimodal programmes and multimodal programmes were included. In patients with ovarian cancer, multimodal prehabilitation resulted in significantly reduced hospital stay and time to chemotherapy. In patients with endometrial and cervical cancer, prehabilitation was associated with significant weight loss, but had no significant effects on surgical complications or mortality. No adverse events of the programmes were reported. Evidence on the effect of prehabilitation for patients with gynaecological cancer is limited. Future studies are needed to determine the effects on postoperative complications and quality of life.

The effect of preoperative smoking and smoke cessation on wound healing and infection in post-surgery subjects: A meta-analysis

A meta-analysis was performed to evaluate the preoperative smoking and smoke cessation on wound healing and infection in post-surgery subjects. A systematic literature search up to January 2022 incorporated 11 trials involving 218 567 subjects after post-surgery at the beginning of the study; 176 670 were smoke cessation or non-smokers, and 41 897 were smokers. Statistical tools like the dichotomous method were used within a random or fixed-influence model to establish the odds ratio (OR) with 95% confidence intervals (CIs) to evaluate the influence of preoperative smoking and smoke cessation on wound healing and infection in post-surgery subjects. Smoke cessation or non-smokers had significantly lower postoperative wound healing problems (OR, 0.59; 95% confidence interval, 0.43-0.82, P < .001), and surgical site wound infection (OR, 0.74; 95% CI, 0.63-0.87, P < .001) compared with smokers in post-surgery subjects. Smoke cessation or non-smokers had significantly lower postoperative wound healing problems, and surgical site wound infection compared with smokers in post-surgery subjects. Furthermore, evidence is needed to confirm the outcomes.

STRONG for Surgery & Strong for Life - against all odds: intensive prehabilitation including smoking, nutrition, alcohol and physical activity for risk reduction in cancer surgery - a protocol for an RCT with nested interview study (STRONG-Cancer)

Background

There is a large unused potential for risk reduction in the preoperative period via effective lifestyle intervention targeting co-existing risky lifestyles: Smoking, malNutrition, obesity, risky Alcohol intake and insufficient Physical activity (SNAP).

This trial compares the efficacy of the integrated STRONG programme with standard care on preoperative risk reduction and secondly on SNAP factor improvement and frailty, postoperative complications and quality of life. A nested interview study explores the patient preferences and the multi-perspective view of patients, relatives and health professionals.

Methods

In total, 42 surgical patients with ≥1 SNAP factor are allocated to individually tailored STRONG programme or usual care during adjuvant chemotherapy prior to radical bladder cancer surgery. The STRONG programme has ≥6 weekly sessions with patient education, motivational and pharmaceutical support. It is based on intensive smoking and alcohol cessation interventions reporting perioperative quit rates > 50%.

Surgical risk reduction is measured as ≥1 step for 1 or more risky lifestyles on the ASA-score, secondly as having no risky SNAP factors, and as any SNAP improvement. The outcomes are validated by measurements and biomarkers. Postoperative complications are categorised according to the Clavien-Dindo classification. Health-related quality of life is measured by EQ-5D.

The patients are followed up after 6 weeks at surgery and 6 weeks and 6 months postoperatively.

A representative sample of the participants, their relatives and the clinical staff are interviewed until data saturation. Transcription, triangulated analyses and data management are conducted using NVivo computer software.

Discussion

The surgical agenda is characterised by fixed dates for surgery focusing on clear risk reduction within a short time. This requires a clinical useful lifestyle intervention programme with a high effect and coverage as well as containing all SNAP factors and tailored to individual needs.

The STRONG programme seems to meet these requirements. After development in multi-professional collaboration, STRONG is delivered by a specially trained nurse as part of the surgical patient journey.

Overall, this study will bring important new knowledge about risk reduction in a frail patient group undergoing major cancer surgery.

Trial registration

Registration at www.clintrials.gov (NCT04088968)

The manuscript form from https://trialsjournal.biomedcentral.com/bmc/journal and the SPIRIT guidelines are followed.