Smoking Cessation After Diagnosis of Lung Cancer Is Associated With a Beneficial Effect on Performance Status

Effectiveness of a self-determination theory-based smoking cessation intervention plus instant messaging via mobile application for smokers with cancer: Protocol for a pragmatic randomized controlled trial

BACKGROUND AND AIMS

Despite evidence that patients living with cancer who continue to smoke after diagnosis are at higher risk for all-cause mortality and reduced treatment efficacy, many cancer patients continue to smoke. This protocol is for a study to test the effectiveness of a self-determination theory-based intervention (quit immediately or progressively) plus instant messaging (WhatsApp or WeChat) to help smokers with cancer to quit smoking.

DESIGN

This will be a multi-centre, two-arm (1:1), single-blind, pragmatic, individually randomized controlled trial.

SETTING

Taking part will be specialist outpatient clinics in five major hospitals in different location-based clusters in Hong Kong.

PARTICIPANTS

The sample will include 1448 Chinese smokers living with cancer attending medical follow-ups at outpatient clinics.

INTERVENTIONS

The intervention group will receive brief advice (approximately 5-8 minutes) from research nurses in the outpatient clinics and then be invited to choose their own quit schedules (immediate or progressive). During the first 6-month follow-up period they will receive instant messaging with smoking cessation advice once per week for the first 3 months, and thereafter approximately once per month. They will also receive four videos, and those opting to quit progressively will receive a smoking reduction leaflet. The control group will also receive brief advice but be advised to quit immediately, and instant messaging with general health advice during the first 6-month follow-up period using the same schedule as the intervention group. Participants in both groups will receive smoking cessation leaflets.

MEASUREMENTS

The primary outcome is biochemically validated smoking abstinence at 6 months, as confirmed by saliva cotinine level and carbon monoxide level in expired air. Secondary outcomes include biochemically validated smoking abstinence at 12 months, self-reported 7-day point prevalence of smoking abstinence at 6 and 12 months, self-reported ≥ 50% reduction of cigarette consumption at 6 and 12 months and quality of life at 6 and 12 months. All time-points for outcomes measures are set after randomization.

COMMENTS

The results could inform research, policymaking and health-care professionals regarding smoking cessation for patients living with cancer, and therefore have important implications for clinical practice and health enhancement.

Continued tobacco use among tobacco-related head and neck cancer patients seeking care in a tertiary care facility, South India

INTRODUCTION

Continued tobacco use in cancer patients leads to decreased treatment efficacy and safety, decreased survival, decreased quality of life, and an increased risk of cancer recurrence and primary tumours at other sites.

OBJECTIVE

To determine the prevalence of continued tobacco usage during the first 6 months of diagnosis among tobacco-related head and neck cancer patients seeking care from a tertiary care centre and the factors associated with it.

METHODS

A facility-based cohort study was conducted at a tertiary care centre in Puducherry, India. Newly diagnosed head and neck cancer patients aged > 18 years with a history of tobacco use were interviewed to gather information on their socio-demographic, clinical characteristics, and tobacco usage. All participants were interviewed again at the 3rd month and at the 6th month during their follow-up visit. The data were entered in EpiData v3.1 and analysed using STATA v14. Multivariable logistic regression analysis was done with continued tobacco use as the dependent variable and variables that were found significantly associated with continued tobacco use in univariate analysis.

RESULTS

Out of 220 study participants at baseline, 157(71 %; 95 % CI: 65.1-77.1) were using tobacco at the time of diagnosis. Out of these 157 participants, 80(50.9 %; 95 % CI; 43.1-58.7) continued to use tobacco at the 3rd month, 63(40.1 %: 95 % CI: 32.6-47.9) continued to use tobacco at the 6th month. The characteristics significantly associated with continued tobacco use are age (less than 39 years and more than 70 years), primary school education, nuclear family, and living alone, smoking tobacco, and increased duration of tobacco use.

CONCLUSION

Two-fifths of head and neck cancer patients with a history of tobacco use continued to use tobacco at the 6th month after diagnosis of cancer. Awareness of effects of tobacco use and the benefits of tobacco cessation needs to be created among cancer patients.

Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement

Background: Fatigue is the most common symptom among cancer survivors. Cancer-related fatigue (CRF) may occur at any point in the cancer care continuum. Multiple factors contribute to CRF development and severity, including cancer type, treatments, presence of other symptoms, comorbidities, and medication side effects. Clinically, increasing physical activity, enhancing sleep quality, and recognizing sleep disorders are integral to managing CRF. Unfortunately, CRF is infrequently recognized, evaluated, or treated in lung cancer survivors despite more frequent and severe symptoms than in other cancers. Therefore, increased awareness and understanding of CRF are needed to improve health-related quality of life in lung cancer survivors. Objectives: 1) To identify and prioritize knowledge and research gaps and 2) to develop and prioritize research questions to evaluate mechanistic, diagnostic, and therapeutic approaches to CRF among lung cancer survivors. Methods: We convened a multidisciplinary panel to review the available literature on CRF, focusing on the impacts of physical activity, rehabilitation, and sleep disturbances in lung cancer. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in the 1) detection and diagnostic evaluation of CRF in lung cancer survivors; 2) timing, goals, and implementation of physical activity and rehabilitation; and 3) evaluation and treatment of sleep disturbances and disorders to reduce CRF. Finally, we present the panel's initial 32 research questions and seven final prioritized questions. Conclusions: This statement offers a prioritized research agenda to 1) advance clinical and research efforts and 2) increase awareness of CRF in lung cancer survivors.

Quitting smoking after a cancer diagnosis is associated with high-risk neutrophil-to-lymphocyte ratio among tobacco use-related cancer survivors

Quitting smoking could potentially minimize the risk of a high neutrophil-to-lymphocyte ratio (NLR) among tobacco use-related (TUR) cancer survivors. A total of 1263 TUR cancer survivors aged 20 to 85 years old were investigated using data from the National Health and Nutritional Examination Survey 1999-2018. The primary outcome was the NLR, which was defined as having two levels: high-risk (≥ 3) and low-risk (< 3). The association between smoking cessation time and a high-risk NLR level was analyzed using weighted logistic regression models. Overall, the current smoking rate of TUR cancer survivors was found to be 21.7%. Older age (75 years above), gender and respiratory-related cancers are covariables associated with high risk of NLR levels for individual who identified as Non-Hispanic White (NHW). Non-Hispanic Black (NHB) (n = 27) who quit smoking after a cancer diagnosis were associated with the highest risk of a high NLR (OR 4.83, 95% CI 1.40-16.61, p = 0.01) compared to NHB nonsmokers (n = 139). These findings suggest that the risk of a high NLR level is strongly associated with the time of smoking cessation in NHB TUR cancer survivors. As a result, NHB TUR cancer survivors should quit smoking as soon as possible because the benefits of quitting smoking were observed over the 5 year period following smoking cessation.

Smoking Cessation after Cancer Diagnosis and Enhanced Therapy Response: Mechanisms and Significance

The adverse effects of smoking on human health have been recognized for several decades, especially in the context of cancer. The ability of tobacco smoke components, including tobacco-specific carcinogens and additive compounds such as nicotine, to initiate or promote tumor growth have been described in hundreds of studies. These investigations have revealed the tumor-promoting activities of nicotine and other tobacco smoke components and have also recognized the ability of these agents to suppress the efficacy of cancer therapy; it is now clear that smoking can reduce the efficacy of most of the widely used therapeutic modalities, including immunotherapy, radiation therapy, and chemotherapy. Several studies examined if continued smoking after cancer diagnosis affected therapy response; it was found that while never smokers or non-smokers had the best response to therapy, those who quit smoking at the time of diagnosis had higher overall survival and reduced side-effects than those who continued to smoke. These studies also revealed the multiple mechanisms via which smoking enhances the growth and survival of tumors while suppressing therapy-induced cell death. In conclusion, smoking cessation during the course of cancer therapy markedly increases the chances of survival and the quality of life.

Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today

Lung cancer is the third most common type of cancer in the UK, with nearly 50 000 new cases diagnosed a year. Treatments for lung cancer have improved in recent years with the advent of new surgical and radiotherapy techniques and the increased use of immunotherapies. These advances have resulted in increasing numbers of patients surviving beyond the completion of their treatment. Lung cancer patients are now not dying from their cancer diagnosis, but from other co-existing pathologies. Lung cancer patients commonly present with multiple comorbidities. Mitigating the effects of poor lifestyles and changing behaviours may improve the efficacy of treatments, reduce side-effects and improve the quality of life for lung cancer patients. Published evidence supports the use of interventions to manage behavioural habits, to optimise the health of patients. There is no consensus as to what, when or how to embed these into the patient pathway. Supporting patients before, during and after their cancer treatments to increase activity, eat well and stop smoking have been seen to decrease side-effects and improve patient outcomes and wellbeing. The challenge is to provide a package of interventions that is acceptable to patients and fits within the patient pathway so as not to conflict with diagnostic and therapeutic activities. This article reviews where we are today with providing behavioural support to optimise the health of lung cancer patients undergoing treatment.

Systematic review of smoking relapse rates among cancer survivors who quit at the time of cancer diagnosis

BACKGROUND

Tobacco cessation, at the time of cancer diagnosis, has been associated with better oncologic outcomes. Cancer diagnosis has been shown to serves as a "teachable moment," inspiring tobacco cessation. However, the sustainability of abstinence from smoking is understudied. Similarly, there is a paucity of data regarding the utility of behavioral/pharmacologic intervention to support continued smoking cessation.

METHODS

A systematic literature review was conducted in August 2021 with no date limits. Relevant studies that reported tobacco smoking relapse rates for patients who quit at the time of cancer diagnosis were included. Our literature search identified 1620 articles and 29 met inclusion criteria. The primary endpoint of the study was smoking relapse rate. Secondary outcome was a descriptive assessment of behavioral and pharmacologic interventions to promote continued cessation. Exploratory outcomes included a regression analysis to examine associations between study factors and relapse rates.

RESULTS

There were 3021 smokers who quit at the time of cancer diagnosis. Weighted overall relapse rate for the study population was 44 % (range 5-57 %). Interventions to support smoking cessation were employed in 17 of the 29 included studies and protocols were heterogenous, including behavioral, pharmacologic, or mixed intervention strategies. Exploratory analysis demonstrated no association between relapse rates and publication year, gender, or study type. Relapse rates were indirectly associated with age (p = .003), suggesting that younger patients were more likely to relapse.

CONCLUSION

The sustainability of smoking cessation after a cancer diagnosis is understudied, and existing literature is difficult to interpret due to heterogeneity. Relapse rates remain significant and, although many studies have included the employment of an intervention to promote continued cessation, few studies have measured the effect of a protocolized intervention to support abstinence.

LKB1 phosphorylation and deactivation in lung cancer by NNAL, a metabolite of tobacco-specific carcinogen, in an isomer-dependent manner

LKB1 loss of function is one key oncogenic event in lung cancer. Clinical data suggest that LKB1 loss of function is associated with patients' smoking status. The responsible ingredients and molecular mechanisms in tobacco for LKB1 loss of function, however, are not defined. In this study, we reported that NNAL, a major metabolite of a tobacco-specific carcinogen NNK, induces LKB1 phosphorylation and its loss of function via the β-AR/PKA signaling pathway in an isomer-dependent manner in human lung cancer cells. NNAL exposure also resulted in enhanced lung cancer cell migration and chemoresistance in an LKB1-dependent manner. A 120-day NNAL exposure in lung cancer cells, mimicking its chronic exposure among smokers, resulted in more prominent LKB1 phosphorylation, cell migration, and chemoresistance even in the absence of NNAL, indicating the long-lasting LKB1 loss of function although such an effect eventually disappeared after NNAL was removed for two months. These observations were confirmed in a lung cancer xenograft model. More importantly, human lung cancer tissues revealed elevated LKB1 phosphorylation in comparison to the paired normal lung tissues. These results suggest that LKB1 loss of function in human lung cancer could be extended to its phosphorylation, which may be mediated by NNAL from tobacco smoke in an isomer-dependent manner via the β-AR/PKA signaling pathway.

Quitting Smoking At or Around Diagnosis Improves the Overall Survival of Lung Cancer Patients: A Systematic Review and Meta-Analysis

INTRODUCTION

Lung cancer (LC) remains a disease with poor prognosis despite recent advances in treatments. Here, we aimed at summarizing the current scientific evidence on whether quitting smoking at or around diagnosis has a beneficial effect on the survival of LC patients.

METHODS

We searched MEDLINE and EMBASE for articles published until 31st October, 2021, that quantified the impact on LC patients' survival of quitting smoking at or around diagnosis or during treatment. Study-specific data were pooled into summary relative risk (SRR) and corresponding 95% confidence intervals (CI) using random effect meta-analysis models.

RESULTS

Twenty-one articles published between 1980 and 2021 were included, which encompassed a total of over 10,000 LC patients. There was substantial variability across studies in terms of design, patients' characteristics, treatments received, criteria used to define smoking status (quitters or continued), and duration of follow-up. Quitting smoking at or around diagnosis was significantly associated with improved overall survival (SRR 0.71, 95% CI 0.64-0.80), consistently among patients with non-small cell LC (SRR 0.77, 95% CI 0.66-0.90, n studies = 8), small cell LC (SRR 0.75, 95% CI 0.57-0.99, n studies = 4), or LC of both or unspecified histological type (SRR 0.81, 95% CI 0.68-0.96, n studies = 6).

CONCLUSIONS

Quitting smoking at or around diagnosis is associated with a beneficial effect on the survival of LC patients. Treating physicians should educate LC patients about the benefits of quitting smoking even after diagnosis and provide them with the necessary smoking cessation support.

A Cost-Effective and Non-Invasive pfeRNA-Based Test Differentiates Benign and Suspicious Pulmonary Nodules from Malignant Ones

The ability to differentiate between benign, suspicious, and malignant pulmonary nodules is imperative for definitive intervention in patients with early stage lung cancers. Here, we report that plasma protein functional effector sncRNAs (pfeRNAs) serve as non-invasive biomarkers for determining both the existence and the nature of pulmonary nodules in a three-stage study that included the healthy group, patients with benign pulmonary nodules, patients with suspicious nodules, and patients with malignant nodules. Following the standards required for a clinical laboratory improvement amendments (CLIA)-compliant laboratory-developed test (LDT), we identified a pfeRNA classifier containing 8 pfeRNAs in 108 biospecimens from 60 patients by sncRNA deep sequencing, deduced prediction rules using a separate training cohort of 198 plasma specimens, and then applied the prediction rules to another 230 plasma specimens in an independent validation cohort. The pfeRNA classifier could (1) differentiate patients with or without pulmonary nodules with an average sensitivity and specificity of 96.2% and 97.35% and (2) differentiate malignant versus benign pulmonary nodules with an average sensitivity and specificity of 77.1% and 74.25%. Our biomarkers are cost-effective, non-invasive, sensitive, and specific, and the qPCR-based method provides the possibility for automatic testing of robotic applications.

Association between Body Mass Index and Immune-Related Adverse Events (irAEs) among Advanced-Stage Cancer Patients Receiving Immune Checkpoint Inhibitors: A Pan-Cancer Analysis

Simple Summary

Currently, clinical studies exploring the impact of high body fat on toxicities after receiving immune checkpoint inhibitors (ICIs) among cancer patients are limited. Here, we analyze data from a health care system serving the mid-Atlantic geographic region to assess how body fat can affect the development of toxicities of ICIs. In our study, body mass index (BMI) was used as the measure of body fat, and the results suggested that cancer patients with a high BMI were more likely to have toxicities after receiving ICIs. Our study suggests that symptom management should be incorporated in the cancer care continuum of patients who receive ICIs, especially those with high BMI. In clinical settings, oncologists should inform cancer patients receiving ICIs with high BMI that their risk of post-treatment toxicities can be higher compared to their counterparts with lower BMI.

Abstract

Evidence regarding the association between body mass index (BMI) and immune-related adverse events (irAEs) among cancer patients receiving immune checkpoint inhibitors (ICIs) is limited. Here, we use cross-sectional hospital-based data to explore their relationship. Pre-treatment BMI was treated as an ordinal variable (<25, 25 to ≤30, ≥30 kg/m²). The outcome of interest was irAEs after ICI initiation. A multivariable logistic regression model estimated the adjusted odds ratio (aOR) and 95% confidence interval (CI) of BMI. A total of 684 patients with stage III or IV cancer were included in the study (lung: 269, melanoma: 204, other: 211). The mean age at the first dose of ICI was 64.1 years (SD = 13.5), 394 patients (57.6%) were male, and over one-third (N = 260, 38.0%) were non-White. Overall, 52.9% of patients had BMI ≥ 25 kg/m² (25 to ≤30: 217, ≥30: 145) and 288 (42.1%) had irAEs after ICI treatment. Patients with higher BMI tended to have a higher rate of irAEs (<25: 35.7%, 25 to ≤30: 47.0%, ≥30: 49.0%). The multivariable logistic regression yielded consistent results (BMI ≥ 30 vs. BMI < 25: aOR = 1.47, 95% CI = 0.96–2.23; 25 ≤ BMI < 30 vs. BMI < 25: aOR = 1.46, 95% CI = 1.02–2.11, p-trend = 0.04). In conclusion, among patients with advanced cancer receiving ICIs, the rate of irAEs appears to be higher among those with higher BMI.

Postdiagnosis Smoking Cessation and Reduced Risk for Lung Cancer Progression and Mortality : A Prospective Cohort Study

BACKGROUND

Lung cancer is the leading cause of cancer death worldwide, and about one half of patients with lung cancer are active smokers at diagnosis.

OBJECTIVE

To determine whether quitting smoking after diagnosis of lung cancer affects the risk for disease progression and mortality.

DESIGN

Prospective study of patients with non-small cell lung cancer (NSCLC) who were recruited between 2007 and 2016 and followed annually through 2020.

SETTING

N.N. Blokhin National Medical Research Center of Oncology and City Clinical Oncological Hospital No. 1, Moscow, Russia.

PATIENTS

517 current smokers who were diagnosed with early-stage (IA-IIIA) NSCLC.

MEASUREMENTS

Probabilities of overall survival, progression-free survival, and lung cancer-specific mortality and hazard ratios (HRs) for all-cause and cancer-specific mortality.

RESULTS

During an average of 7 years of follow-up, 327 (63.2%) deaths, 273 (52.8%) cancer-specific deaths, and 172 (33.7%) cases of tumor progression (local recurrence or metastasis) were recorded. The adjusted median overall survival time was 21.6 months higher among patients who had quit smoking than those who continued smoking (6.6 vs. 4.8 years, respectively; P = 0.001). Higher 5-year overall survival (60.6% vs. 48.6%; P = 0.001) and progression-free survival (54.4% vs. 43.8%; P = 0.004) were observed among patients who quit than those who continued smoking. After adjustments, smoking cessation remained associated with decreased risk for all-cause mortality (HR, 0.67 [95% CI, 0.53 to 0.85]), cancer-specific mortality (HR, 0.75 [CI, 0.58 to 0.98]), and disease progression (HR, 0.70 [CI, 0.56 to 0.89]). Similar effects were observed among mild to moderate and heavy smokers and patients with earlier and later cancer stages.

LIMITATION

Exposure measurements were based on self-reported questionnaires.

CONCLUSION

Smoking cessation after diagnosis materially improved overall and progression-free survival among current smokers with early-stage lung cancer.

PRIMARY FUNDING SOURCE

International Agency for Research on Cancer.

Interest in Cessation Treatment Among People Who Smoke in a Community-Based Multidisciplinary Thoracic Oncology Program

INTRODUCTION

To evaluate the need for tobacco cessation services within a multidisciplinary clinic (MDC), we surveyed patients on their smoking status, interest in quitting, and willingness to participate in a clinic-based cessation program. We further evaluated the association between interest in cessation or willingness to participate in a cessation program and overall survival (OS).

METHODS

From 2014 to 2019, all new patients with lung cancer in the MDC at Baptist Cancer Center (Memphis, TN) were administered a social history questionnaire to evaluate their demographic characteristics, smoking status, tobacco dependence, interest in quitting, and willingness to participate in a cessation program. We used chi-square tests and logistic regression to compare characteristics of those who would participate to those who would not or were unsure and Kaplan-Meier curves and Cox regression to evaluate the association between cessation interest or willingness to quit and OS.

RESULTS

Of 641 total respondents, the average age was 69 years (range: 32-95), 47% were men, 64% white, 34% black, and 17% college graduates. A total of 90% had ever smoked: 34% currently and 25% quit within the past year. Among the current smokers, 60% were very interested in quitting and 37% would participate in a cessation program. Willingness to participate in a cessation program was associated with greater interest in quitting (p < 0.0001), better OS (p = 0.02), and reduced hazard of death (hazard ratio = 0.52, 95% confidence interval: 0.30-0.88), but no other characteristics.

CONCLUSIONS

Patients with lung cancer in an MDC expressed considerable interest in tobacco cessation services; patients willing to participate in a clinic-based cessation program had improved survival.

Effectiveness of smoking cessation interventions for smokers with chronic diseases: A systematic review

AIMS

To systematically summarize seminal studies on the design and effectiveness of smoking cessation interventions targeted at patients with chronic diseases through a critical appraisal of the literature.

DESIGN

A systematic review.

DATA SOURCES

This review included literature identified through a search of six databases up to June 2020.

REVIEW METHODS

This review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions. The literature search was limited to English-language articles on the effectiveness of smoking cessation interventions for smokers who were aged ≥18 years and diagnosed with chronic diseases. Data were extracted using the Cochrane Data collection form for intervention reviews of randomized controlled trials and non-randomized controlled trials. The articles were subjected to a quality assessment.

RESULTS

Ten relevant articles were identified. The designs of the interventions were highly heterogeneous, and only six articles reported a significant increase in smoking abstinence among patients with chronic diseases. In the target population, an intervention delivered by healthcare professionals on an intensive schedule was shown to more effectively induce smoking cessation, compared with minimal counselling. However, methodological flaws were identified in most of the included studies.

CONCLUSION

The findings of this review suggest that additional efforts are needed to design smoking cessation interventions for patients with chronic diseases and that further examination of the effectiveness and feasibility of these interventions is warranted.

IMPACT

What problem did the study address? This review evaluated the effectiveness of smoking cessation interventions targeted at patients with chronic diseases. What were the main findings? An intervention with an intensive schedule that was delivered by healthcare professionals was shown to more effectively induce smoking cessation in patients with chronic diseases, compared with minimal counselling. More attention and resources should be directed towards smokers with no intention to quit, especially those with chronic diseases. There is an urgent need for generic smoking cessation interventions that use novel approaches to address the unique needs of this population and to integrate such evidence-based interventions into routine care. Where and on whom will the research have impact? The findings of this review may guide nurses, who play a prominent role in raising the issue of smoking cessation with patients, to design appropriate smoking cessation interventions for patients with chronic diseases. The resulting improvements in patients' health would not only benefit patients themselves but also reduce the burden of chronic diseases on healthcare systems.

Care to Quit: a stepped wedge cluster randomised controlled trial to implement best practice smoking cessation care in cancer centres

BACKGROUND

Cigarette smoking in people with cancer is associated with negative treatment-related outcomes including increased treatment toxicity and complications, medication side effects, decreased performance status and morbidity. Evidence-based smoking cessation care is not routinely provided to patients with cancer. The purpose of this study is to determine the effectiveness of a smoking cessation implementation intervention on abstinence from smoking in people diagnosed with cancer.

METHODS

A stepped wedge cluster randomised design will be used. All sites begin in the control condition providing treatment as usual. In a randomly generated order, sites will move to the intervention condition. Based on the Theoretical Domains Framework, implementation of Care to Quit will include (i) building the capability and motivation of a critical mass of key clinical staff and identifying champions; and (ii) identifying and implementing cessation care models/pathways. Two thousand one hundred sixty patients with cancer (diagnosed in the prior six months), aged 18+, who report recent combustible tobacco use (past 90 days or in the 30 days prior to cancer diagnosis) and are accessing anti-cancer therapy, will be recruited at nine sites. Assessments will be conducted at baseline and 7-month follow-up. The primary outcome will be 6-month abstinence from smoking. Secondary outcomes include biochemical verification of abstinence from smoking, duration of quit attempts, tobacco consumption, nicotine dependence, provision and receipt of smoking cessation care, mental health and quality of life and cost effectiveness of the intervention.

DISCUSSION

This study will implement best practice smoking cessation care in cancer centres and has the potential for wide dissemination.

TRIAL REGISTRATION

The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN ( ACTRN12621000154808 ) prior to the accrual of the first participant and will be updated regularly as per registry guidelines.

Smoking Behavior in Patients With Early-Stage NSCLC: A Report From ECOG-ACRIN 1505 Trial

INTRODUCTION

Smoking cessation has been reported to benefit patients even after a diagnosis of lung cancer. We studied the smoking behavior of patients who participated in a phase 3 trial of adjuvant therapy following resection of stages IB-IIIA NSCLC.

METHODS

The ECOG-ACRIN 1505 was conducted to determine whether the addition of bevacizumab to adjuvant chemotherapy would improve overall survival (OS) for patients with early-stage NSCLC. Studying the association between smoking status and OS was a secondary end point. Patients completed a questionnaire on their smoking habits at baseline, 3, 6, 9, and 12 months.

RESULTS

A total of 1501 patients were enrolled, and 99.8%, 95%, 94%, 93%, and 93% responded to the questionnaire at baseline, 3, 6, 9, and 12 months, respectively. A total of 90% reported a current or previous history of cigarette smoking. In addition, 60% of nonsmokers at enrollment reported smoking after diagnosis (before randomization); however, 1% of them reported smoking at 12 months. Furthermore, 94% of the respondents smoked none/fewer cigarettes daily at 12 months. The incidence of grades 3-5 toxicity on treatment was 68%, 76%, and 72% in never, former, and current smokers, respectively (p = 0.05). The disease-free survival for never-smokers relative to current and former smokers was (hazard ratio [HR] 0.93, p = 0.64 and HR 1.05, p = 0.72), and OS was (adjusted HR for death 0.54, p = 0.005 and adjusted HR for death 0.68, p = 0.03), respectively.

CONCLUSIONS

This is the first comprehensive, prospective report of smoking habits in patients with NSCLC patients from a phase III early-stage trial. There was a high rate of smoking reduction and cessation following study entry. The disease-free survival did not differ significantly between smokers and never smokers, though there were less grade 3-5 toxicities and more favorable OS in never-smokers.

Smoking Cessation at a Safety-Net Hospital: A Radiation Oncology Resident-Led Quality Improvement Initiative

Purpose

Continued smoking among patients with cancer has been associated with increased toxicities, resistance to treatment, and recurrence. This resident-led quality improvement study attempted to increase smoking cessation by providing free smoking cessation medications in the radiation oncology clinic.

Methods and Materials

Twenty currently smoking patients with nonmetastatic cancer were prospectively enrolled. First line treatment was protocol-standardized combined nicotine replacement therapy (patches and lozenges). Therapy was initiated before radiation therapy and given for 12 weeks. Patient self-reported tobacco use was assessed at midtreatment, end of 12-week treatment, 3-month follow-up, 6-month follow-up, and 12-month follow-up.

Results

Within the initial cohort of 20 patients, average years smoked was 36.3 years (median = 37.5). In addition, 85% had attempted to quit previously. Among patients initially enrolled, 3 did not initiate radiation therapy, and 4 were removed from the study by midtreatment due to noncompliance. Midway through treatment, patients had cut self-reported cigarette use to 31% of baseline. However, 75% or more of patients had smoked within the last week at all timepoints assessed. With further follow-up, the number of cigarettes smoked daily continued to rise, reaching 61% of baseline by the 12-month follow-up.

Conclusions

Patients reduced cigarette consumption, but all patients eventually resumed smoking during the 12-month follow-up. Although it is unfortunate that this study did not result in long-term smoking cessation, the results demonstrate the difficulties faced in helping patients with cancer quit, particularly patients seen at a safety-net hospital. Future efforts could be directed at intensified smoking cessation programs, likely incorporating a more standardized counseling component.

European practice patterns and barriers to smoking cessation after a cancer diagnosis in the setting of curative versus palliative cancer treatment

BACKGROUND

Smoking cessation after a cancer diagnosis is associated with improved overall survival. Few studies have reported oncologists' cessation practice patterns, but differences between the curative and palliative settings have not been described. We aimed to study the oncologist's perceptions on patients' tobacco use, current practices and barriers to providing smoking cessation support, while distinguishing between treatment with curative (C) and palliative (P) intent.

METHODS

In 2019, an online 34-item survey was sent to approximately 6235 oncologists from 16 European countries. Responses were descriptively reported and compared by treatment setting.

RESULTS

Responses from 544 oncologists were included. Oncologists appeared to favour addressing tobacco in the curative setting more than in the palliative setting. Oncologists believe that continued smoking impacts treatment outcomes (C: 94%, P: 74%) and that cessation support should be standard cancer care (C: 95%, P: 63%). Most routinely assess tobacco use (C: 93%, P: 78%) and advise patients to stop using tobacco (C: 88%, P: 54%), but only 24% (P)-39% (C) routinely discuss medication options, and only 18% (P)-31% (C) provide cessation support. Hesitation to remove a pleasurable habit (C: 13%, P: 43%) and disbelieve on smoking affecting outcomes (C: 3%, P: 14%) were disparate barriers between the curative and palliative settings (p < 0.001), but dominant barriers of time, resources, education and patient resistance were similar between settings.

CONCLUSION

Oncologists appear to favour addressing tobacco use more in the curative setting; however, they discuss medication options and/or provide cessation support in a minority of cases. All patients who report current smoking should have access to evidence-based smoking cessation support, also patients treated with palliative intent given their increasing survival.

Smoking Status Among Patients With Newly Diagnosed Lung Cancer in Taiwan

Background

Continued smoking after receiving a diagnosis of cancer seriously affects disease prognosis and survival. The prevalence and risk factors of continued smoking among patients with newly diagnosed lung cancer are unknown in Taiwan.

Purpose

The aims of this study were to assess the smoking status of patients with newly diagnosed lung cancer and to identify the characteristics that are associated with different smoking statuses.

Methods

Baseline data of a longitudinal study on smoking behaviors after lung cancer diagnosis were analyzed in this study. Patients were consecutively recruited from three medical centers in northern Taiwan. A structured questionnaire and medical chart reviews were used to collect data. Multinomial logistic regression analysis was used to examine the factors associated with continuing to smoke after being diagnosed with lung cancer.

Results

Among the 406 patients with newly diagnosed lung cancer who were recruited, 47.0% were never-smokers and 53.0% were ever-smokers. Among the second group, 38% were former smokers, 18% were recent quitters, and 44% were current smokers. Compared with former smokers, current smokers were more likely to be younger (OR = 1.05), to not exercise regularly (OR = 2.74), to currently live with smokers (OR = 2.48), and to have lower self-efficacy for refusing to smoke (OR = 0.95). Compared with recent quitters, current smokers were more likely to have lower self-efficacy for refusing to smoke.

Conclusions/Implications for Practice

A significant proportion of ever-smoker lung cancer patients in Taiwan will continue to smoke after receiving their diagnosis. Variables known to modify the risk factors associated with continued smoking such as regular exercise and better refusal self-efficacy should be considered and incorporated into future smoking cessation programs for patients with lung cancer.

CheckMate 171: A phase 2 trial of nivolumab in patients with previously treated advanced squamous non-small cell lung cancer, including ECOG PS 2 and elderly populations

BACKGROUND

CheckMate 171 (NCT02409368) is an open-label, multicentre, phase 2 trial of nivolumab in previously treated advanced squamous non-small cell lung cancer (NSCLC), conducted as part of a post-approval commitment to the European Medicines Agency (EMA). We report outcomes from this trial.

METHODS

Patients with Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2 and disease progression during/after ≥1 systemic treatment (≥1 being platinum-based chemotherapy) for advanced or metastatic disease were treated with nivolumab 3 mg/kg every 2 weeks until progression or unacceptable toxicity. The primary end-point was incidence of grade 3-4 treatment-related select adverse events (AEs). Other end-points included overall survival (OS) and safety.

RESULTS

Of 811 patients treated, 103 had ECOG PS 2; 278 were aged ≥70 years and 125 were ≥75 years of age. Minimum follow-up was ~18 months. Safety was similar across populations; the most frequent grade 3-4 treatment-related select AEs in all treated patients were diarrhoea (1%), increased alanine aminotransferase (ALT, 1%), pneumonitis (0.7%), colitis (0.6%) and increased aspartate aminotransferase (AST, 0.5%). Median OS was similar in all treated patients and those aged ≥70 and ≥75: 10.0 months, 10.0 months and 11.2 months, respectively. Median OS was 5.2 months in patients with ECOG PS 2.

CONCLUSION

These results suggest that nivolumab is well tolerated and active in patients with advanced, relapsed squamous NSCLC, including the elderly, with OS outcomes consistent with phase 3 data. In patients with ECOG PS 2, nivolumab had similar tolerability, but outcomes were worse, as expected in this difficult-to-treat, poor prognosis population.

CLINICAL TRIAL REGISTRATION

NCT02409368.

[Bronchial carcinoma and tobacco: An update]

Lung cancer remains the most lethal cancer. The most common cause is smoking, which is also preventable, unlike the causes of other types of cancer. A genetic characteristic has emerged over several years, which explains particular profiles of smokers, or highly dependent smokers. The emergence of new therapies for the treatment of lung cancer, and the impact of tobacco on reducing the effectiveness of these therapies must challenge practitioners to obtain a complete cessation of smoking regardless of the stage of the disease.

Estimation of the Risk of Lung Cancer in Women Participating in a Population-Based Breast Cancer Screening Program

INTRODUCTION

Lung cancer mortality is increasing in women. In Spain, estimates suggest that lung cancer mortality may soon surpass breast cancer mortality, the main cause of cancer mortality among women. The aim of this study was to estimate the proportion of women at high risk of developing lung cancer in a group of participants in a population-based breast cancer screening program.

METHODS

Cross-sectional study in a sample of women who participated in a population-based breast cancer screening program in 2016 in Hospitalet de Llobregat (n=1,601). High risk of lung cancer was defined according to the criteria of the National Lung Screening Trial (NLST) and the Dutch-Belgian randomized lung cancer screening trial (NELSON).

RESULTS

Around 20% of smokers according to NLST criteria and 40% of smokers according to NELSON criteria, and around 20% of former smokers according to both criteria, are at high risk of developing lung cancer. A positive and statistically significant trend is observed between the proportion of women at high risk and nicotine dependence measured with the brief Fagerström test.

CONCLUSIONS

A high proportion of participants in this breast cancer screening program have a high risk of developing lung cancer and would be eligible to participate in a lung cancer screening program. Population-based breast cancer screening programs may be useful to implement lung cancer primary prevention activities.

Somatic genome alterations in relation to age in lung adenocarcinoma

Lung adenocarcinoma (LUAD) is the most common cause of global cancer-related mortality and the major risk factor is smoking consumption. By analyzing 486 LUAD samples from The Cancer Genome Atlas, we detected a higher mutational burden among younger patients in the global cohort as well as in the TP53-mutated subcohort. The interaction effect of patient age and TP53 mutations significantly affected the mutational rate of younger TP53-mutated patients. Furthermore, we detected a significant enrichment of the smoking-related signature SI4 (SI4) among younger TP53-mutated patients, meanwhile the age-related Signature 1 (SI1) significantly increased in proportion to patient age. Although present and past smoking is reported in the TP53 wild-type patients, we observed a lower average number of somatic mutations, with no correlation with patient age. Overall, TP53 mutations were significantly higher in younger patients and mainly characterized by SI4 and Signature 24 (SI24). Therefore, TP53 seemed to acquire a particular sensitivity to smoking related C>A mutations in younger patients. We hypothesize that TP53 mutations at a younger age might be a crucial factor enhancing the sensitivity to smoking-related mutations leading to a burst of somatic alterations. The mutational profile of cancer cell might reflect the mutational processes operative in aging in a given tissue. Therefore, TP53-mutated and TP53 wild-type patient groups might represent phenotypes which endure aging-related mutational processes with different strength. Our study provides indications of age-dependent differences in mutational backgrounds that might be relevant for cancer prevention and age-adjusted treatment approaches.

Continued smoking after a cancer diagnosis: a longitudinal study of intentions and attempts to quit

PURPOSE

Continued smoking after a cancer diagnosis is associated with poor treatment outcomes and reduced life expectancy. We aimed to identify the stability of smoking status after diagnosis including quit attempts and quit intentions.

METHODS

Participants with a first primary cancer diagnosis were recruited via two state-based registries in Australia. Questionnaires were mailed at approximately 6 months (T1), 1 year (T2), 2 years (T3), and 3.5 years (T4) post-diagnosis. Smoking status and quitting intentions were assessed at each time point.

RESULTS

A cohort of 1444 people was recruited. People who indicated that they were more than 9 months post-diagnosis are excluded from analysis, leaving 1407 eligible study participants. Sixty-six (37%) of the 178 self-reported smokers at diagnosis had quit in the 6-month post-diagnosis (T1), the remaining 112 (63%) reported being a current smoker. Of the smokers at T1, 40% intended to quit: with 8% having quit smoking by T2; 11% quit by T3; 12% quit by T4. Of those who reported at T1 that they intended to quit in the next 6 months, 10% or fewer reported having quit at any subsequent time point. Quitting attempts decreased in frequency over time post-diagnosis. Less than 15% of respondents who had quit at or shortly before diagnosis reported relapse to smoking at each time point.

CONCLUSIONS

The majority of smokers diagnosed with cancer continue to smoke beyond diagnosis, even in the context of an intention to quit and attempts to do so. Cancer survivors who smoke remain motivated to quit well beyond the initial diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

There are clear positive clinical effects of smoking cessation for those who have undergone treatment for cancer, both for short-term treatment outcomes, and for long-term survivorship. Given the substantial rates of continued smoking among those who report smoking at diagnosis and their continued attempts to quit during survivorship, there is a need for improved cessation support initiatives for people diagnosed with cancer. These initiatives need to continue to be offered to smokers long after the initial diagnosis and treatment.

Interventions for smoking cessation in people diagnosed with lung cancer

BACKGROUND

Lung cancer is one of the most common causes of death from cancer worldwide. Smoking induces and aggravates many health problems, including vascular diseases, respiratory illnesses and cancers. Tobacco smoking constitutes the most important risk factor for lung cancer. Most people with lung cancer are still active smokers at diagnosis or frequently relapse after smoking cessation. Quitting smoking is the most effective way for smokers to reduce the risk of premature death and disability. People with lung cancer may benefit from stopping smoking. Whether smoking cessation interventions are effective for people with lung cancer and whether one method of quitting is more effective than any other has not been systematically reviewed.

OBJECTIVES

To determine the effectiveness of smoking cessation programmes for people with lung cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (accessed via PubMed) and Embase up to 22 December 2018. We also searched the American Society of Clinical Oncology (ASCO) Annual Meeting proceedings, the lung cancer sections of the proceedings of the ESMO Congress, the lung cancer sections of the proceedings of the European Conference of Clinical Oncology (ECCO) Congress, the World Conference on Lung Cancer proceedings, the Society for Research on Nicotine and Tobacco Annual Meeting from 2013, the Food and Drug Administration website, the European Medicine Agency for drug registration website, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) to 30 December 2018. We applied no restriction on language of publication.

SELECTION CRITERIA

We planned to include any randomised controlled trial (RCT) of any psychosocial or pharmacological smoking cessation intervention or combinations of both, compared with no intervention, a different psychosocial or pharmacological (or both) intervention or placebo for pharmacological interventions in people with lung cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies from the initial search for potential trials for inclusion. We planned to use standard methodological procedures expected by Cochrane. We found no trials that met the inclusion criteria.

MAIN RESULTS

We identified no RCTs that met our inclusion criteria. Among the 1817 records retrieved using our search strategy, we retrieved 19 studies for further investigation. We excluded 15 trials: ten trials because we could not distinguish people with lung cancer from the other participants, or the participants were not people with lung cancer, four because they were not randomised, or RCTs. We excluded one trial because, though it was completed in 2004, no results are available. We assessed four ongoing trials for inclusion when data become available.

AUTHORS' CONCLUSIONS

There were no RCTs that determined the effectiveness of any type of smoking cessation programme for people with lung cancer. There was insufficient evidence to determine whether smoking cessation interventions are effective for people with lung cancer and whether one programme is more effective than any other. People with lung cancer should be encouraged to quit smoking and offered smoking cessation interventions. However, due to the lack of RCTs, the efficacy of smoking cessation interventions for people with lung cancer cannot be evaluated and concluded. This systematic review identified a need for RCTs to explore these.

Impact of current versus former smoking status on the outcomes of non-metastatic non-small cell lung cancer treated with upfront surgery; findings from the National Lung Screening Trial

Objective: To evaluate the impact of current versus former smoking status on the outcomes of non-metastatic non-small cell lung cancer (NSCLC) treated with upfront surgery. Methods: This is a post-hoc analysis of patients diagnosed with NSCLC, stage I-III within the National Lung Screening Trial (NLST). Kaplan-Meier analysis was used to delineate the impact of smoking status on overall survival. Moreover, Cox regression analyses were utilized to assess factors predicting overall and lung cancer-specific survival. Results: A total of 773 patients were included in the current study. Former smokers (at the time of randomization of the NLST study) were 338 patients while current smokers were 435 patients. For overall survival, former smokers have better outcomes compared to current smokers (P = 0.023). Within multivariate Cox regression analysis, the following factors were predictive of worse overall survival: older age (P = 0.037), male gender (P = 0.022), current smoking (P = 0.022), advanced stage (P < 0.001) and preexisting stroke (P = 0.015). Likewise, the following factors were predictive of worse lung cancer-specific survival in multivariate Cox regression analysis: current smoking (P = 0.009) and advanced stage (P < 0.001). Conclusions: Among patients with early-stage NSCLC treated with upfront surgery, current smokers have worse overall and lung cancer-specific survival compared to former smokers. Expert opinion: Among patients with non-metastatic NSCLC treated with upfront surgical resection, current smokers have worse overall, lung cancer-specific and progression-free survival compared to former smokers. Smoking cessation counseling should be incorporated into management strategies of early stage NSCLC.

SIPA1L3 methylation modifies the benefit of smoking cessation on lung adenocarcinoma survival: an epigenomic-smoking interaction analysis

Smoking cessation prolongs survival and decreases mortality of patients with non‐small‐cell lung cancer (NSCLC). In addition, epigenetic alterations of some genes are associated with survival. However, potential interactions between smoking cessation and epigenetics have not been assessed. Here, we conducted an epigenome‐wide interaction analysis between DNA methylation and smoking cessation on NSCLC survival. We used a two‐stage study design to identify DNA methylation–smoking cessation interactions that affect overall survival for early‐stage NSCLC. The discovery phase contained NSCLC patients from Harvard, Spain, Norway, and Sweden. A histology‐stratified Cox proportional hazards model adjusted for age, sex, clinical stage, and study center was used to test DNA methylation–smoking cessation interaction terms. Interactions with false discovery rate‐q ≤ 0.05 were further confirmed in a validation phase using The Cancer Genome Atlas database. Histology‐specific interactions were identified by stratification analysis in lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC) patients. We identified one CpG probe (cg02268510_SIPA1L3) that significantly and exclusively modified the effect of smoking cessation on survival in LUAD patients [hazard ratio (HR)_interaction = 1.12; 95% confidence interval (CI): 1.07–1.16; P = 4.30 × 10^–7]. Further, the effect of smoking cessation on early‐stage LUAD survival varied across patients with different methylation levels of cg02268510_SIPA1L3. Smoking cessation only benefited LUAD patients with low methylation (HR = 0.53; 95% CI: 0.34–0.82; P = 4.61 × 10^–3) rather than medium or high methylation (HR = 1.21; 95% CI: 0.86–1.70; P = 0.266) of cg02268510_SIPA1L3. Moreover, there was an antagonistic interaction between elevated methylation of cg02268510_SIPA1L3 and smoking cessation (HR_interaction = 2.1835; 95% CI: 1.27–3.74; P = 4.46 × 10⁻³). In summary, smoking cessation benefited survival of LUAD patients with low methylation at cg02268510_SIPA1L3. The results have implications for not only smoking cessation after diagnosis, but also possible methylation‐specific drug targeting.

Pan-Asian adapted Clinical Practice Guidelines for the management of patients with metastatic non-small-cell lung cancer: a CSCO-ESMO initiative endorsed by JSMO, KSMO, MOS, SSO and TOS

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of metastatic non-small-cell lung cancer (NSCLC) was published in 2016. At the ESMO Asia Meeting in November 2017 it was decided by both ESMO and the Chinese Society of Clinical Oncology (CSCO) to convene a special guidelines meeting immediately after the Chinese Thoracic Oncology Group Annual Meeting 2018, in Guangzhou, China. The aim was to adapt the ESMO 2016 guidelines to take into account the ethnic differences associated with the treatment of metastatic NSCLC cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with metastatic NSCLC representing the oncological societies of China (CSCO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices and the drug availability and reimbursement situations in the six participating Asian countries. During the review process, the updated ESMO 2018 Clinical Practice Guidelines for metastatic NSCLC were released and were also considered, during the final stages of the development of the Pan-Asian adapted Clinical Practice Guidelines.

Somatic genome alterations in relation to age in lung squamous cell carcinoma

Lung squamous cell carcinoma (LUSC) is the most common cause of global cancer-related mortality and the major risk factors is smoking consumption. By analyzing ∼500 LUSC samples from The Cancer Genome Atlas, we detected a higher mutational burden as well as a higher level of methylation changes in younger patients. The SNPs mutational profiling showed enrichments of smoking-related signature 4 and defective DNA mismatch repair (MMR)-related signature 6 in younger patients, while the defective DNA MMR signature 26 was enriched among older patients. Furthermore, gene set enrichment analysis was performed in order to explore functional effect of somatic alterations in relation to patient age. Extracellular Matrix-Receptor Interaction, Nucleotide Excision Repair and Axon Guidance seem crucial disrupted pathways in younger patients. We hypothesize that a higher sensitivity to smoking-related damages and the enrichment of defective DNA MMR related mutations may contribute to the higher mutational burden of younger patients. The two distinct age-related defective DNA MMR signatures 6 and 26 might be crucial mutational patterns in LUSC tumorigenesis which may develop distinct phenotypes. Our study provides indications of age-dependent differences in mutational backgrounds (SNPs and CNVs) as well as epigenetic patterns that might be relevant for age adjusted treatment approaches.

Helping cancer patients quit smoking using brief advice based on risk communication: A randomized controlled trial

This randomized controlled trial aimed to examine the effectiveness of a smoking cessation intervention using a risk communication approach. A total of 528 smoking cancer patients were randomly allocated either into an intervention group (n = 268) to receive brief advice based on risk communication by a nurse counselor or a control group (n = 260) to receive standard care. Subjects in both groups received a smoking cessation booklet. Patient follow-ups were at 1 week and at 1, 3, 6, 9 and 12 months. No significant differences were found in self-reported point-prevalence 7-day abstinence between the intervention and control groups at 6 months (15.7% vs 16.5%; OR 0.94, 95% CI 0.59-1.50). The rate of at least 50% self-reported reduction of smoking at 6 months, was higher in the intervention group than in the control group (16.8% vs 12.3%; OR 1.43, 95% CI 0.88-2.35). The biochemically validated quit rate at the 6-month follow-up was higher in the intervention group than in the control group (5.2% vs 3.8%; OR 1.38, 95% CI 0.60-3.16). These data suggest that advice based on risk communication was not effective for quitting but improved the rate of smoking reduction among smoking cancer patients.

A smoking cessation programme for current and recent ex-smokers following diagnosis of a potentially curable cancer

BACKGROUND

Cancer patients who quit smoking have improved survival rates. The time of diagnosis provides a 'teachable moment' when healthcare providers can offer smoking-cessation treatment.

AIMS

To assess the impact on quit rates of a tailored smoking-cessation intervention for patients diagnosed with a potentially curable cancer.

METHODS

A prospective, one-arm cohort study of current smokers and recent quitters (<30 days) who had commenced treatment for a potentially curable cancer was performed. Intervention involved an initial motivational interview, regular follow up and pharmacotherapy when appropriate. Quit rates were measured at 1, 3, 6 and 12 months by self-reported abstinence and biochemical confirmation. The primary end point was prolonged abstinence at 12 months. Changes in quality of life parameters and distress were also assessed.

RESULTS

Seventy-one patients were recruited, with a median age of 56 years. Forty-one patients (58%) had a smoking-related cancer. The prolonged abstinence rate at 12 months was 24% (95% confidence interval 14-36%). Factors associated with successful quitting included being in the preparation or action phase of readiness to change at study entry (P = 0.012) and having complications of treatment requiring hospitalisation (P = 0.024). Between baseline and 12 months, quitters reported improvement in self-control (P < 0.001) and reduced levels of distress (P = 0.03) compared to non-quitters.

CONCLUSION

Patients who continue to smoke after being diagnosed with cancer require intensive support to quit. An individualised behavioural and pharmacological intervention can be successful in helping patients quit smoking, with quality of life improvements seen amongst successful quitters. Population measures to stop people starting smoking remain essential.

The Effects of smoking status and smoking history on patients with brain metastases from lung cancer

There is limited data on the effects of smoking on lung cancer patients with brain metastases. This single institution retrospective study of patients with brain metastases from lung cancer who received stereotactic radiosurgery assessed whether smoking history is associated with overall survival, local control, rate of new brain metastases (brain metastasis velocity), and likelihood of neurologic death after brain metastases. Patients were stratified by adenocarcinoma versus nonadenocarcinoma histologies. Kaplan-Meier analysis was performed for survival endpoints. Competing risk analysis was performed for neurologic death analysis to account for risk of nonneurologic death. Separate linear regression and multivariate analyses were performed to estimate the brain metastasis velocity. Of 366 patients included in the analysis, the median age was 63, 54% were male and, 60% were diagnosed with adenocarcinoma. Current smoking was reported by 37% and 91% had a smoking history. Current smoking status and pack-year history of smoking had no effect on overall survival. There was a trend for an increased risk of neurologic death in nonadenocarcinoma patients who continued to smoke (14%, 35%, and 46% at 6/12/24 months) compared with patients who did not smoke (12%, 23%, and 30%, P = 0.053). Cumulative pack years smoking was associated with an increase in neurologic death for nonadenocarcinoma patients (HR = 1.01, CI: 1.00-1.02, P = 0.046). Increased pack-year history increased brain metastasis velocity in multivariate analysis for overall patients (P = 0.026). Current smokers with nonadenocarcinoma lung cancers had a trend toward greater neurologic death than nonsmokers. Cumulative pack years smoking is associated with a greater brain metastasis velocity.

Impact of smoking on lung cancer treatment effectiveness: a review

Tobacco smoke contains more than 4000 detectable substances, such as polycyclic aromatic hydrocarbons, nicotine, carbon monoxide and heavy metals, which are considered powerful enzymatic inducers that have notable influence on the efficacy and tolerability of many medications through complex pharmacokinetic and pharmacodynamic interactions. As a result, adjustments of drug dosages are required in smokers, both if they continue to smoke or if they quit after smoking cessation treatment. The purpose of this review is to examine the main drug interactions with tobacco smoke clinically relevant, with a closer look on patients developing oncologic diseases.

[Systematizing support in cessation smoking to improve care for cancer patients]

Approximately 20% of cancer patients smoke at diagnosis (all localizations included), and over two thirds continue despite the therapeutic management of their cancer, especially when cancer is not associated with tobacco. The impact of smoking on quality of care for patients is actually not enough considered. A literature review conducted by the French National Cancer Institute emphasizes the importance of tobacco cessation to improve the prognosis (decreased mortality from all causes and specific); to reduce the risk of second primary cancers; to reduce per- and post-surgical risks as long as some toxicities related to treatments and to improve the quality of physical and mental life of patients. It is important that a communication with the patient takes place at the beginning of the treatment to impact the smoking behavior. All oncology health professionals should deliver a clearly and personalized cessation advice in the light of scientific data and ensure that smoking cessation help will be offered to the patient.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

[Consequences of tobacco smoking on lung cancer treatments]

In France, in 2010, tobacco induced 81% of deaths by lung cancer corresponding to about 28,000 deaths. Continued smoking after diagnosis has a significant impact on treatment. In patients with lung cancer, the benefits of smoking cessation are present at any stage of disease. For early stages, smoking cessation decreases postoperative morbidity, reduces the risk of second cancer and improves survival. Previous to surgery, smoking cessation of at least six to eight weeks or as soon as possible is recommended in order to reduce the risk of infectious complications. Tobacco could alter the metabolism of certain chemotherapies and targeted therapies, such as tyrosine kinase inhibitors of the EGF receptor, through an interaction with P450 cytochrome. Toxicity of radiations could be lower in patients with lung cancer who did not quit smoking before treatment. For patients treated by radio-chemotherapy, overall survival seems to be better in former smokers but no difference is observed in terms of recurrence-free survival. For advanced stages, smoking cessation enhances patients' quality of life. Smoking cessation should be considered as full part of lung cancer treatment whatever the stage of disease.

Interventions for smoking cessation in people diagnosed with lung cancer

BACKGROUND

Lung cancer is one of the most common causes of death from cancer worldwide. Smoking induces and aggravates many health problems, including vascular diseases, respiratory illnesses and cancers. Tobacco smoking constitutes the most important risk factor for lung cancer. Most people with lung cancer are still active smokers at diagnosis or frequently relapse after smoking cessation. Quitting smoking is the most effective way for smokers to reduce the risk of premature death and disability. People with lung cancer may benefit from stopping smoking. Whether smoking cessation interventions are effective for people with lung cancer and whether one method of quitting is more effective than any other has not been systematically reviewed.

OBJECTIVES

To determine the effectiveness of smoking cessation programmes for people with lung cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (accessed via PubMed) and EMBASE up to 22 June 2015. We also searched the American Society of Clinical Oncology (ASCO) Annual Meeting proceedings, the lung cancer sections of the proceedings of the ESMO Congress, the lung cancer sections of the proceedings of the European Conference of Clinical Oncology (ECCO) Congress, the World Conference on Lung Cancer proceedings, the Society for Research on Nicotine and Tobacco Annual Meeting from 2013, the Food and Drug Administration website, the European Medicine Agency for drug registration website, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) to 1 July 2015. We applied no restriction on language of publication.

SELECTION CRITERIA

We planned to include any randomised controlled trial (RCT) of any psychosocial or pharmacological smoking cessation intervention or combinations of both, compared with no intervention, a different psychosocial or pharmacological (or both) intervention or placebo for pharmacological interventions in people with lung cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies from the initial search for potential trials for inclusion. We planned to use standard methodological procedures expected by Cochrane. We found no trials that met the inclusion criteria.

MAIN RESULTS

We identified no RCTs that met our inclusion criteria. Among the 1052 records retrieved using our search strategy, we retrieved 13 studies for further investigation. We excluded 10 trials: five trials because we could not distinguish people with lung cancer from the other participants, or the participants were not people with lung cancer, four because they were not randomised, or RCTs. We excluded one trial because, though it was completed in 2004, no results are available. We assessed three ongoing trials for inclusion when data become available.

AUTHORS' CONCLUSIONS

There were no RCTs that determined the effectiveness of any type of smoking cessation programme for people with lung cancer. There was insufficient evidence to determine whether smoking cessation interventions are effective for people with lung cancer and whether one programme is more effective than any other. People with lung cancer should be encouraged to quit smoking and offered smoking cessation interventions. However, due to the lack of RCTs, the efficacy of smoking cessation interventions for people with lung cancer cannot be evaluated and concluded. This systematic review identified a need for RCTs to explore these.

Systematic Review of Tobacco Use after Lung or Head/Neck Cancer Diagnosis: Results and Recommendations for Future Research

Tobacco use after cancer diagnosis is associated with adverse cancer outcomes, yet reliable prevalence estimates for this behavior are lacking. We conducted a systematic literature review of the prevalence of current tobacco use among individuals with a history of lung or head/neck cancer (CRD #42012002625). An extensive search of electronic databases (MEDLINE, EMBASE, Cochrane Library, CINAHL, PsycINFO, and Web of Science) identified 7,777 potentially relevant articles published between 1980 and 2014 and 131 of these yielded pertinent information. Aggregating results across heterogeneous study designs and diverse patient samples, the overall mean prevalence rate of current tobacco use (mostly cigarette smoking) was 33.0% (median, 31.0%). Among current tobacco users at cancer diagnosis, the mean prevalence rate of current tobacco use (mostly cigarette smoking) was 53.8% (median, 50.3%). In many cases, an operational definition of "current" tobacco use was absent, and biochemical verification of self-reported smoking status was infrequent. These and other observed methodologic limitations in the assessment and reporting of cancer patients' tobacco use underscore the necessity of uniform tobacco use assessment in future clinical research and cancer care.

[Influence of tobacco smoking on quality of life in patients with lung cancer]

Tobacco smoking is the leading cause of lung cancer. This cancer is the most specific indicator of the effects of tobacco on health. Regardless of the type of lung cancer and the stage of the disease, continued smoking has a negative impact on its development and its treatment. For this reason, smoking cessation is an essential step in the management of patients with lung cancer who smoke. It has been clearly demonstrated that quality of life is worse in smokers than in non-smokers. The aim of this general review is to study the relationship between tobacco use and quality of life specifically in patients with lung cancer. Among the twelve studies selected, six of them clearly demonstrate a deleterious effect of continued smoking tobacco or a beneficial effect of smoking cessation on the quality of life in patients with lung cancer. These findings should lead clinicians to offer support to smokers with lung cancer in order to assist them to quit smoking.

Helping cancer patients quit smoking by increasing their risk perception: a study protocol of a cluster randomized controlled trial

Background

Despite smoking cessation can largely improve cancer prognosis and quality of life, many patients continued smoking after the diagnosis of cancer. This study aims to test the effectiveness of a smoking cessation intervention using risk communication approach to help cancer patients quit smoking, and to improve their health related quality of life.

Methods

A cluster randomized controlled trial will be employed. Cancer patients who continued smoking after the diagnosis of cancer and have medical follow-up at the out-patient clinics of the five acute hospitals in Hong Kong will be invited to participate. Subjects in the experimental group will receive (1) health warnings of smoking based on a special designed leaflet; and (2) a patient-centred counseling from nurse counselors with emphasis on risk perceptions of smoking to cancer prognosis. Additionally, they will receive two more telephone counseling at 1-week and 1-month. Control group receive standard care and a generic self-help smoking cessation booklet. Outcomes measure include (a) self-reported and the biochemically validated quit rate, (b) patient’s smoking reduction by at least 50 % compared to baseline, (c) quit attempt(s), (d) change in the intention to quit, (e) change in risk perceptions of smoking, and (f) change in health related quality of life.

Discussion

This study will make an important contribution to evidence-based practice by testing the effectiveness of a tailored smoking cessation intervention for cancer patients. The results will support the development of clinical practice guidelines to promote smoking cessation in cancer patients to improve their prognosis and quality of life.

Trial registration

ClinicalTrials.gov NCT01685723. Registered 9 November 2012.