The effect of smoking on outcome following external radiation for localized prostate cancer

Smoking status among cancer patients by specialty: A U.S. nationwide representative analysis

BACKGROUND

Persistence in tobacco use among cancer survivors has been associated with a multitude of clinicodemographic factors. However, there is a paucity of understanding regarding the role the healthcare professional's specialty plays in tobacco cessation in tobacco-related cancer survivors.

METHODS

We conducted a cross-sectional analysis of data from cancer survivors with a smoking history using the Behavioral Risk Factor Surveillance System (BRFSS) database to examine differences in the proportion of patients continuing tobacco use among patients with a diagnosis of cancer segregated by cancer site specialty over the 2016-2020 period. We accounted for complex survey design and used sampling weights to obtain a nationwide representative sample. We employed modified Poisson regression adjusting for age, gender, education, income, race, marital status, and medical specialty.

RESULTS

We analyzed 19,855 cancer survivors with a current or past history of tobacco use, of whom 5222 (26,3%) self-reported to be current smokers. Patients with urological and gynecological tobacco-related malignancies had a higher relative risk (RR) of being current smokers with a RR of 1.30 (95% confidence interval, 1.12-1.51) and 1.25 (95% confidence interval, 1.12-1.39) respectively. Malignant Hematology had the lowest RR of smoking status among all other specialties RR 0.85 (95% confidence interval, 0.59-1.21).

CONCLUSIONS

Continuing smoking rates among tobacco-related cancer survivors were different between specialties. One in four cancer survivors were current smokers; this emphasizes health professionals' paramount role in tobacco cessation counseling.

Post-diagnostic health behaviour scores and risk of prostate cancer progression and mortality

BACKGROUND

Individual behaviours are associated with prostate cancer (PC) progression. Behavioural scores, comprised of multiple risk factors, allow assessment of the combined impact of multiple behaviours.

METHODS

We examined the association between six a priori scores and risk of PC progression and mortality among 2156 men with PC in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) cohort: two scores developed based on the PC survivorship literature ('2021 Score [+ Diet]'); a score developed based on pre-diagnostic PC literature ('2015 Score'); and three scores based on US recommendations for cancer prevention ('WCRF/AICR Score') and survival ('ACS Score [+ Alcohol]'). Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for progression and PC mortality via parametric survival models (interval censoring) and Cox models, respectively.

RESULTS

Over a median (IQR) of 6.4 (1.3, 13.7) years, we observed 192 progression and 73 PC mortality events. Higher (i.e., healthier) 2021 Score + Diet and WCRF/AICR Scores were inversely associated with risk of PC progression (2021 + Diet: HRcontinuous = 0.76, 95% CI: 0.63-0.90.

WCRF/AICR

HRcontinuous = 0.83, 95% CI: 0.67-1.02) and mortality (2021 + Diet: HRcontinuous = 0.65, 95% CI: 0.45-0.93.

WCRF/AICR

HRcontinuous = 0.71; 95% CI: 0.57-0.89). The ACS Score + Alcohol was only associated with progression (HRcontinuous = 0.89, 95% CI: 0.81-0.98) while the 2021 Score was only associated with PC mortality (HRcontinuous = 0.62, 95% CI: 0.45-0.85). The 2015 was not associated with PC progression or mortality.

CONCLUSION

Findings strengthen the evidence that behavioural modifications following a prostate cancer diagnosis may improve clinical outcomes.

Post-diagnostic health behaviour scores in relation to fatal prostate cancer

BACKGROUND

Individual health behaviours have been associated with fatal prostate cancer (PCa). Their combined association with fatal PCa after diagnosis is unknown.

METHODS

This prospective cohort included 4518 men diagnosed with nonmetastatic PCa from the Health Professionals Follow-up Study. Exposures included a three-factor score integrating post-diagnostic fatal PCa risk factors ("2021 PCa Behaviour Score"), six-factor score integrating incident aggressive PCa risk factors ("2015 PCa Behaviour Score"), and two scores integrating recommendations for cancer prevention and survival, respectively. Multivariable Cox models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for fatal PCa.

RESULTS

Over a median 10.2 years, we observed 219 PCa deaths. Each additional point of one of the PCa-specific health behaviour scores (2015 PCa Behaviour Score) was associated with a 19% reduced fatal PCa risk (HR: 0.81, 95%CI: 0.68-0.97). The 2021 PCa Behaviour Score and scores integrating national recommendations were not associated with fatal PCa.

CONCLUSIONS

While a PCa-specific health behaviour score was associated with a reduced risk of fatal PCa, we did not otherwise observe strong evidence of associations between post-diagnostic scores and fatal PCa. Avoiding tobacco, healthy body size, and physical activity may decrease PCa death risk, but further research is needed to inform cancer survivorship recommendations.

Clinical impact of cigarette smoking on the outcomes of allogeneic hematopoietic stem cell transplantation: a multicenter retrospective study

Smoking is associated with a high risk for different diseases including respiratory tract infections in immunocompetent patients. However, data about the effects of cigarette smoking on the outcomes of allogeneic hematopoietic stem cell transplantation (allo-HSCT) are limited. Therefore, we retrospectively investigated 608 patients aged ≥20 years with hematological disorders who received their first allo-HSCT at our group of hospitals between 2000 and 2015, and evaluated the impact of cigarette smoking before allo-HSCT on clinical outcomes by dividing patients into two groups according to the Brinkman index (BI) (nonsmokers or light smokers [BI: 0-500] and heavy smokers [BI: ≥ 500]). Multivariate analyses showed that heavy smoking was associated with a high 5-year cumulative incidence of chronic graft-versus-host disease (cGVHD) (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 1.15-2.61, p < 0.01). The 5-year overall survival (HR: 1.16, 95% CI: 0.86-1.58, p = 0.33) and disease-free survival (HR: 1.12, 95% CI: 0.83-1.52, p = 0.45) were similar between the two groups. Hence, cigarette smoking is correlated with cGVHD, although prospective studies must be conducted to further verify this result.

Impact of Tobacco Smoking on Outcomes of Radiotherapy: A Narrative Review

The carcinogenic role of tobacco smoking is well recognized, but the detrimental effects of continued smoking after a cancer diagnosis have been underestimated. Radiotherapy is among the main treatment modalities for cancer. We reviewed the literature data concerning the impact of tobacco smoking on treatment outcomes in radiotherapy-managed patients with various malignancies. Most of the analyzed studies demonstrated the detrimental effect of smoking on overall survival, tumor control, quality of life, treatment toxicity, and the incidence of second primary malignancies. Healthcare professionals should use the cancer diagnosis and treatment as a teachable moment and recommend their patients to immediately cease smoking. Wherever possible, cancer patients should undergo an intensive smoking-cessation program, including behavioral and pharmacologic therapy.

Post-Diagnostic Dietary and Lifestyle Factors and Prostate Cancer Recurrence, Progression, and Mortality

PURPOSE OF REVIEW

This study aimed to summarize evidence published between 1999 and June 2020 examining diet and lifestyle after prostate cancer (PC) diagnosis in relation to risk of biochemical recurrence, PC progression, and PC-specific mortality.

RECENT FINDINGS

Secondary prevention is an important research area in cancer survivorship. A growing number of studies have reported associations between post-diagnostic modifiable behaviors and risk of PC outcomes. Evidence on modifiable lifestyle factors and PC remains limited. Where multiple studies exist, findings are often mixed. However, studies consistently suggest that smoking and consumption of whole milk/high-fat dairy are associated with higher risk of PC recurrence and mortality. In addition, physical activity and ½ to 1 glass of red wine/day have been associated with lower risk of recurrence and PC-specific mortality. Greater inclusion of racially/ethnically diverse groups in future research is necessary to understand these relationships in populations most impacted by adverse PC outcomes.

Clinical factors affecting prostate-specific antigen levels in prostate cancer patients undergoing radical prostatectomy: a retrospective study

Background:

Since prostate-specific antigen (PSA) levels can be influenced by some routinely available clinical factors, a retrospective study was conducted to explore the influence of obesity, smoking habit, heavy drinking and chronic obstructive pulmonary disease on PSA levels in men with histologically confirmed prostate cancer.

Patients & methods:

We reviewed the medical records of 833 prostate cancer patients undergoing radical prostatectomy.

Results:

Serum PSA levels at the time of surgery were not associated with either BMI or history of chronic obstructive pulmonary disease or heavy drinking. Conversely, PSA levels were associated with smoking status.

Conclusion:

Among the clinical factors explored in this homogeneous population, only tobacco use was associated with PSA levels, which should be considered when using PSA-based screening in male smokers.

Smokers with prostate cancer tend to show higher PSA levels at the time of radical prostatectomy. As higher PSA levels are associated with a worse prognosis, smoking habit may have a prognostic value in prostate cancer. Further studies are required to explore the underlying biology of this finding.

Smoking status and pathological response to neoadjuvant chemotherapy among patients with bladder cancer: a pooled analysis

Background

Smoking status has been confirmed as an independent prognostic factor for bladder cancer. However, for patients who received neoadjuvant chemotherapy (NAC), the influence of smoking status on the pathological response and prognosis remains unclear. This pooled analysis aimed to investigate whether smoking status is an independent risk factor for pathological response, recurrence, and prognosis in patients with bladder cancer who undergo NAC.

Methods

We searched PubMed, Web of Science, Embase, Cochrane Library, and Google Scholar for related studies published between 1990 and 2017. In total, 10 studies comprising 1,382 patients with muscle-invasive bladder cancer were included. The odds ratio (OR) and 95% confidence interval (CI) of complete pathological response, partial pathological response, overall survive (OS), recurrence, and cancer-specific mortality (CSM) were chosen as outcome measures. Analyses were performed using Review Manager (version 5.3, The Cochrane Collaboration, UK) and Stata statistical software (version 15, Stata Corp., USA).

Results

Compared to nonsmokers, smokers were less likely to have a complete pathologic response (OR =0.55, 95% CI: 0.35–0.87) and partial pathological response (OR =0.57, 95% CI: 0.37–0.88). However, we found no significant association between smoking status and overall survival (OR =0.71, 95% CI: 0.28–1.80), recurrence (OR =1.35, 95% CI: 0.97–1.88), and cancer-specific mortality (OR =0.90, 95% CI: 0.62–1.32).

Conclusions

Smoking reduces both complete and partial pathological response rate to NAC in patients with bladder cancer. Thus, smoking status should be given more importance when developing treatment plans and evaluating efficacy, particularly of NAC, among bladder cancer patients.

Effect of Smoking on Oncological Outcome among Prostate Cancer Patients after Radical Prostatectomy with Neoadjuvant Hormonal Therapy

We analyzed the association between smoking and oncological outcome after radical prostatectomy with neoadjuvant hormonal therapy. This study included men who had undergone radical prostatectomy with neoadjuvant hormonal therapy between 2003 and 2016. We evaluated the association between clinicopathological factors and smoking status as well as the prognostic significance of smoking status in biochemical recurrence. The patients' backgrounds were comparable between smokers and nonsmokers. Smoking status were identified as significant risk factors of biochemical recurrence. Smoking was a risk factor of biochemical recurrence, suggesting that smoking may promote cancer recurrence after surgical treatment combined with hormonal therapy.

Diet and Lifestyle in Prostate Cancer

A variety of diet and lifestyle factors have been studied with respect to prostate cancer risk in large, prospective cohort studies. In spite of this work, and in contrast to other common cancers, few modifiable risk factors have been firmly established as playing a role in prostate cancer. There are several possible explanations for the lack of well-established risk factors. First, prostate cancer has among the highest heritability of all common cancers; second, early life exposures may play an important role in risk, rather than mid- and later-life exposures assessed in most epidemiological studies. Finally, prostate-specific antigen (PSA) screening plays a critical role in prostate cancer detection and incidence rates, which has important implications for epidemiological studies.Among modifiable risk factors, smoking and obesity are consistently associated with higher risk specifically of advanced prostate cancer. There is also considerable evidence for a positive association between dairy intake and overall prostate cancer risk, and an inverse association between cooked tomato/lycopene intake and risk of advanced disease. Several other dietary factors consistently associated with risk in observational studies, including selenium and vitamin E, have been cast into doubt by results from clinical trials. Results for other well-studied dietary factors, including fat intake, red meat, fish, vitamin D, soy and phytoestrogens are mixed.In practical terms, men concerned with prostate cancer risk should be encouraged to stop smoking, be as physically active as possible, and achieve or maintain a healthy weight. These recommendations also have the advantage of having a positive impact on risk of type 2 diabetes, cardiovascular disease, and other chronic diseases. Reducing dairy intake while increasing consumption of fish and tomato products is also reasonable advice.

Association of Smoking Status With Recurrence, Metastasis, and Mortality Among Patients With Localized Prostate Cancer Undergoing Prostatectomy or Radiotherapy: A Systematic Review and Meta-analysis

Importance

Studies investigating the association of cigarette smoking with prostate cancer incidence and outcomes have revealed controversial results.

Objective

To systematically review and analyze the association of smoking status with biochemical recurrence, metastasis, and cancer-specific mortality among patients with localized prostate cancer undergoing primary radical prostatectomy or radiotherapy.

Data Sources

A systematic search of original articles published between January 2000 and March 2017 was performed using PubMed, MEDLINE, Embase, and Cochrane Library databases in March 2017.

Study Selection

Observational studies reporting Cox proportional hazards regression or logistic regression analyses were independently screened.

Data Extraction and Synthesis

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Available multivariable hazard ratios (HRs) and corresponding 95% CIs were included in quantitative analysis. A risk-of-bias assessment was completed for nonrandomized studies.

Main Outcomes and Measures

Prespecified outcomes of interest were biochemical recurrence, metastasis, and cancer-specific mortality.

Results

A total of 5157 reports were identified, of which 16 articles were selected for qualitative analysis and 11 articles were selected for quantitative analysis. All included studies were observational and nonrandomized and comprised a total of 22 549 patients. Overall, 4202 patients (18.6%) were current smokers. The overall median follow-up was 72 months. Current smokers had a statistically significantly higher risk of biochemical recurrence (HR, 1.40; 95% CI, 1.18-1.66; P < .001 [10 studies]), as did former smokers (HR, 1.19; 95% CI, 1.09-1.30; P < .001 [7 studies]). Current smokers were also at a higher risk of metastasis (HR, 2.51; 95% CI, 1.80-3.51; P < .001 [3 studies]) and cancer-specific mortality (HR, 1.89; 95% CI, 1.37-2.60; P < .001 [5 studies]), whereas former smokers were not (metastasis: HR, 1.61; 95% CI, 0.65-3.97; P = .31 [2 studies]; cancer-specific mortality: HR, 1.05; 95% CI, 0.81-1.37; P = .70 [4 studies]).

Conclusions and Relevance

Current smokers at the time of primary curative treatment for localized prostate cancer are at higher risk of experiencing biochemical recurrence, metastasis, and cancer-specific mortality.

Smoking history, intensity, and duration and risk of prostate cancer recurrence among men with prostate cancer who received definitive treatment

PURPOSE

To examine the association of smoking history and multiple measures of smoking intensity and duration with risk of biochemical recurrence in men treated for prostate cancer.

METHODS

We conducted a prospective cohort study of 1641 men (773 ever-smokers) treated with radical prostatectomy or radiation between 2003 and 2010. The association between ever-smoking and risk of biochemical recurrence was examined using Cox Proportional Hazards models with adjustment for confounders. Among ever-smokers, we further assessed the association between multiple measures of smoking duration and intensity and risk of biochemical recurrence.

RESULTS

In the full cohort, we observed no association between ever-smoking and risk of biochemical recurrence. However, among ever-smokers, a smoking duration of greater than or equal to 10 years was significantly associated with biochemical recurrence (hazard ratio: 2.32, 95% confidence interval: 1.01, 5.33). Our results also suggested that greater than or equal to 10 pack-years of smoking may be associated with an increased risk of biochemical recurrence (hazard ratio: 1.75, 95% confidence interval: 0.97, 3.15). No association was observed between packs smoked per day or years since smoking cessation (among former smokers) and risk of biochemical recurrence.

CONCLUSION

Smoking duration is a significant predicator of biochemical recurrence among men with prostate cancer who are current or former smokers.

The Epidemiology of Prostate Cancer

Prostate cancer is a major cause of disease and mortality among men, and each year 1.6 million men are diagnosed with and 366,000 men die of prostate cancer. In this review, we discuss the state of evidence for specific genetic, lifestyle, and dietary factors associated with prostate cancer risk. Given the biological heterogeneity of this cancer, we focus on risk factors for advanced or fatal prostate cancer. First, we provide descriptive epidemiology statistics and patterns for prostate cancer incidence and mortality around the world. This includes discussion of the impact of prostate-specific antigen screening on prostate cancer epidemiology. Next, we summarize evidence for selected risk factors for which there is strong or probable evidence of an association: genetics, obesity and weight change, physical activity, smoking, lycopene and tomatoes, fish, vitamin D and calcium, and statins. Finally, we highlight future directions for prostate cancer epidemiology research.

Tobacco smoking and survival after a prostate cancer diagnosis: A systematic review and meta-analysis

BACKGROUND

While a number of studies indicate tobacco smoking has a detrimental impact on survival and recurrence after a prostate cancer diagnosis, there has been no quantitative review of this literature and it is unclear whether tobacco smoking affects clinical populations differentially. We conducted a systematic review and meta-analysis to investigate the associations between tobacco smoking and overall (OM) and prostate cancer-specific (PSM) mortality and recurrence after a prostate cancer diagnosis.

METHODS

EMBASE and ISI Web of Science were searched for English-language studies, published up to August 17, 2017, which conducted a survival analysis to estimate the association between tobacco smoking and OM, PSM and/or recurrence. A random-effects meta-analysis was conducted to estimate the summary hazard ratios (HRs) for the associations between tobacco smoking and the three outcomes.

RESULTS

A total of 28 studies met the inclusion criteria. The results of the primary meta-analysis indicate current smokers have significantly poorer overall survival (Summary HR = 1.96, 95% CI = 1.69, 2.28), prostate cancer-specific survival (Summary HR = 1.79, 95% CI = 1.47, 2.20) and recurrence-free survival (Summary HR = 1.48, 95% CI = 1.28, 1.72) than never smokers. Similar results were found in population-based studies and in studies conducted in specific clinical populations.

CONCLUSIONS

The results of this systematic review and meta-analysis indicate that tobacco smoking at prostate cancer diagnosis is associated with a significantly increased risk of overall mortality, prostate-cancer specific mortality and recurrence. We recommend future studies collect more detailed information about tobacco smoking to further understanding of the association between tobacco smoking and PCa prognosis. In addition, further research should concentrate on the impact of smoking cessation post-diagnosis and post-treatment on prognosis, and the feasibility and effectiveness of smoking cessation programs.

The association of weight change in young adulthood and smoking status with risk of prostate cancer recurrence

The decades before prostate cancer diagnosis represent an etiologically relevant time period for prostate cancer carcinogenesis. However, the association of weight gain in young adulthood with subsequent biochemical recurrence among men with prostate cancer is not well studied, particularly among smokers. We conducted a prospective cohort study of 1,082 men with prostate cancer and treated with either radical prostatectomy or radiation between 2003 and 2010. The association of weight at age 20, weight at age 50 and weight change from age 20 to age 50 with biochemical recurrence was assessed using Cox Proportional Hazards with adjustment for confounders. Stratum-specific hazard ratio (HR) estimates by smoking status were evaluated. In the overall cohort, weight at age 20 (HR per 30 kg: 1.56, 95% confidence interval (CI): 1.02, 2.38, p-trend: 0.039), weight at age 50 (HR per 30 kg: 1.80, 95% CI: 1.32, 2.47, p-trend: <0.001) and weight change from age 20 to age 50 (HR per 30 kg: 1.84, 95% CI: 1.24, 2.74, p-trend: 0.003) were associated with biochemical recurrence. In stratified analyses, weight change from age 20 to age 50 was significantly associated with biochemical recurrence only in former smokers (HR per 30 kg: 3.87, 95% CI: 1.88, 8.00, p-trend: <0.001) and ever smokers (HR per 30 kg: 2.38, 95% CI: 1.27, 4.45, p-trend: 0.007). No significant association was observed between weight gain in young adulthood and biochemical recurrence in never smokers. Our study adds further evidence that weight gain during early adult years conveys long-term risk for adverse cancer outcomes.

Latest Evidence on the Impact of Smoking, Sports, and Sexual Activity as Modifiable Lifestyle Risk Factors for Prostate Cancer Incidence, Recurrence, and Progression: A Systematic Review of the Literature by the European Association of Urology Section of Oncological Urology (ESOU)

CONTEXT

Smoking, sexual activity, and physical activity (PA) are discussed as modifiable lifestyle factors associated with prostate cancer (PCa) development and progression.

OBJECTIVE

To evaluate the available evidence concerning the association of smoking, sexual activity, and sports and exercise on PCa risk, treatment outcome, progression, and cancer-specific mortality.

EVIDENCE ACQUISITION

A systematic review of studies published between 2007 and 2017 using MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement criteria was conducted.

EVIDENCE SYNTHESIS

While data concerning the impact of smoking on PCa development remain conflicting, there is robust evidence that smoking is associated with aggressive tumor features and worse cancer-related outcome, which seems to be maintained for 10 yr after smoking cessation. Less convincing and limited evidence exists for the association of sexual activity with PCa risk. The findings related to PA and PCa support the inference that exercise might be a useful factor in the prevention of PCa and tumor progression, while it is not finally proved under which specific conditions PA might be protective against disease development.

CONCLUSIONS

Smoking is associated with aggressive tumor features and worse cancer-related prognosis; as this negative impact seems to be maintained for 10yr after smoking cessation, urologists should advise men to quit smoking latest at PCa diagnosis to improve their prognosis. As several studies indicate a positive impact of exercise on tumor development, progression, and treatment outcome, it is certainly reasonable to advocate an active lifestyle. Least convincing evidence is available for the interaction of sexual activity and PCa, and well-conducted and longitudinal studies are clearly necessary to evaluate whether the suggested associations between PCa risk and sexual behavior are real or spurious.

PATIENT SUMMARY

In this systematic review, we looked at the impact of smoking, sexual activity, and sports and exercise on prostate cancer risk and outcome after treatment. While the evidence for sexual activity is not overall clear, we found that smoking might lead to more aggressive cancers and result in worse treatment outcome. Physical activity might prevent prostate cancer and improve cancer-related outcomes as well. Hence, it is certainly reasonable to advocate an active lifestyle and advise men to quit smoking.

[What do prostate cancer patients know about smoking? : Results of a bicentric questionnaire study (KRAUT study)]

BACKGROUND

According to the results of a recent meta-analysis, cancer-specific mortality of prostate cancer (PCA) patients is enhanced by 24 % in case of a positive smoking history with a dose-dependent impact of smoking. Until now it is unknown whether this information actually reaches the patients and how extensively an informational discussion about this topic is pursued by physicians.

OBJECTIVE

Three study hypotheses were defined: (1) the knowledge of PCA patients about the potential relationship between tumor progression and cigarette consumption is low, (2) only in rare cases has a clear statement been provided by treating physicians including the explicit advice to stop smoking, and (3) there was a direct association between tumor stage and the extent of cigarette consumption.

MATERIALS AND METHODS

A questionnaire comprising 23 items was developed and validated with 25 uro-oncological patients prior to study start. Between September 2013 and December 2014 a total of 124 PCA patients (median age 65 years) from two urology departments were included in this questionnaire-based survey.

RESULTS

The study population comprised 43 % (n = 54), 39 % (n = 48), and 18 % (n = 22) nonsmokers, former smokers and active smokers, respectively. Active and former smokers differed insignificantly in the number of pack-years only (24.8 vs. 23.7 years, p = 0.995). Of the patients, 56 % regarded an influence of cigarette consumption on the PCA-specific prognosis as possible. However, because a significant (p < 0.001) number of patients wrongly suspected smoking to be causative for PCA development, their knowledge about PCA prognosis is supposedly not based on adequate knowledge. Two of 22 active smokers (9.1 %), 5 of 48 former smokers (10.4 %), and 2 of 54 nonsmokers (3.7 %) had an informational discussion with their urologist about the association of cigarette consumption and PCA-related prognosis (a further 9.1, 4.2 and 3.7 %, respectively, received this information solely from other medical specialties). Only 1 of 22 active smokers (4.5 %) was offered medical aids for smoking cessation by the general practitioner; none of the patients received such support by an urologist. There was no association between a positive smoking history or number of pack-years and PCA tumor stage.

CONCLUSIONS

Education of PCA patients about the relationship between cigarette consumption and cancer-related prognosis is currently inadequate. Following the latest findings on this topic, urologists should pursue informational discussions with their patients, thereby strengthening their position as the primary contact person for decision making in PCA management.

Tobacco use and outcome in radical prostatectomy patients

Cigarette smoking has been consistently associated with increased risk of overall mortality, but the importance of smoking for patients with prostate cancer (CaP) who are candidates for curative radical prostatectomy (RP) has received less attention. This retrospectively designed cohort study investigated the association of smoking history at RP with subsequent CaP treatment outcomes and overall mortality. A total of 1981 patients who underwent RP at Roswell Park Cancer Institute (RPCI) between 1993 and 2014 were studied. Smoking history was considered as a risk factor for overall mortality as well as for currently accepted CaP treatment outcomes (biochemical failure, treatment failure, distant metastasis, and disease‐specific mortality). The associations of smoking status with these outcomes were tested by Cox proportional hazard analyses. A total of 153 (8%) patients died during follow‐up. Current smoking at diagnosis was a statistically significant predictor of overall mortality after RP (current smokers vs. former and never smokers, hazards ratio 2.07, 95% confidence interval [CI]: 1.36–3.14). This association persisted for overall mortality at 3, 5, and 10 years (odds ratios 2.07 [95% CI: 1.36–3.15], 2.05 [95% CI: 1.35–3.12], and 1.8 [95% CI: 1.18–2.74], respectively). Smoking was not associated with biochemical failure, treatment failure, distant metastasis, or CaP‐specific mortality, and the association of smoking with overall mortality did not appear to be functionally related to treatment or biochemical failure, or to distant metastasis. Smoking is a non‐negligible risk factor for death among CaP patients who undergo RP; patients who smoke are far more likely to die of causes other than CaP.

Adverse Health Outcomes Associated with Postdiagnosis Smoking in Prostate Cancer Patients: A Literature Review

This literature review presents what is currently known about the association between postdiagnosis smoking and adverse health outcomes in prostate cancer. A literature search was conducted using Ovid Embase and Ovid MEDLINE. Information from 36 studies was summarized. There is strong evidence across the included studies of higher overall mortality and biochemical recurrence in current smokers diagnosed with prostate cancer. In addition, enhanced adverse effects following surgery, radiation, and hormone therapy have also been identified in current smokers of this population.

[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.

Smoking Is Associated with Acute and Chronic Prostatic Inflammation: Results from the REDUCE Study

Both anti- and proinflammatory effects of cigarette smoking have been described. As prostate inflammation is common, we hypothesized smoking could contribute to prostate inflammation. Thus, we evaluated the association of smoking status with acute and chronic inflammation within the prostate of men undergoing prostate biopsy. We retrospectively analyzed 8,190 men ages 50 to 75 years with PSA levels between 2.5 and 10 ng/mL enrolled in the Reduction by Dutasteride of Prostate Cancer Events study. Smoking status was self-defined as never, former, or current. Prostate inflammation was assessed by systematic central review blinded to smoking status. The association of smoking with inflammation in the baseline, 2-year, and 4-year biopsies was evaluated with univariable and multivariable logistic regressions. At study enrollment, 1,233 (15%), 3,203 (39%), and 3,754 (46%) men were current, former, and never smokers, respectively. Current smokers were significantly younger and had smaller prostates than former and never smokers (all P < 0.05). Former smokers were significantly heavier than current and never smokers (P < 0.001). Acute and chronic prostate inflammations were identified in 1,261 (15%) and 6,352 (78%) baseline biopsies, respectively. In univariable analysis, current smokers were more likely to have acute inflammation than former (OR, 1.35; P, 0.001) and never smokers (OR, 1.36; P, 0.001). The results were unchanged at 2- and 4-year biopsies. In contrast, current smoking was linked with chronic inflammation in the baseline biopsy, but not at 2- and 4-year biopsies. In conclusion, among men undergoing prostate biopsy, current smoking was independently associated with acute and possibly chronic prostate inflammations.

The biological and clinical effects of smoking by patients with cancer and strategies to implement evidence-based tobacco cessation support

Tobacco use is an established risk factor for the development of several cancers; however, far less work has been done to understand the effects of continued smoking on cancer treatment outcomes, and structured tobacco cessation efforts are not well incorporated into the standard care for patients with cancer. In this Review we discuss the known biological effects of smoking on cancer cell biology and emphasise the clinical effects of continued smoking in patients with cancer treated with chemotherapy or radiotherapy. Although evidence supports the need for inclusion of dedicated tobacco cessation efforts for patients with cancer, clinicians should consider the methods used to provide evidence-based tobacco cessation support and the available resources to deliver and maintain consistent tobacco cessation support. We also address the variables to consider in the design and implementation of a sustainable tobacco cessation programme.

A systematic review and meta-analysis of tobacco use and prostate cancer mortality and incidence in prospective cohort studies

CONTEXT

An association between tobacco smoking and prostate cancer (PCa) incidence and mortality was suggested in an earlier meta-analysis of 24 prospective studies in which dose-response associations and risks per unit of tobacco use were not examined.

OBJECTIVE

We investigated the association between several measures of tobacco use and PCa mortality (primary outcome) and incidence (secondary outcome) including dose-response association.

EVIDENCE ACQUISITION

Relevant articles from prospective studies were identified by searching the PubMed and Web of Science databases (through January 21, 2014) and reference lists of relevant articles. Combined relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random effects methods. We also calculated population attributable risk (PAR) for smoking and PCa mortality.

EVIDENCE SYNTHESIS

We included 51 articles in this meta-analysis (11823 PCa deaths, 50349 incident cases, and 4,082,606 cohort participants). Current cigarette smoking was associated with an increased risk of PCa death (RR: 1.24; 95% CI, 1.18-1.31), with little evidence for heterogeneity and publication bias. The number of cigarettes smoked per day had a dose-response association with PCa mortality (p=0.02; RR for 20 cigarettes per day: 1.20). The PAR for cigarette smoking and PCa deaths in the United States and Europe were 6.7% and 9.5%, respectively, corresponding to >10000 deaths/year in these two regions. Current cigarette smoking was inversely associated with incident PCa (RR: 0.90; 95% CI, 0.85-0.96), with high heterogeneity in the results. However, in studies completed in 1995 or earlier (considered as completed before the prostate-specific antigen screening era), ever smoking showed a positive association with incident PCa (RR: 1.06; 95% CI, 1.00-1.12) with little heterogeneity.

CONCLUSIONS

Combined evidence from observational studies shows a modest but statistically significant association between cigarette smoking and fatal PCa. Smoking appears to be a modifiable risk factor for PCa death.

PATIENT SUMMARY

Smoking increases the chance of prostate cancer death. Not smoking prevents this harm and many other tobacco-related diseases.

Smoking and risk of low- and high-grade prostate cancer: results from the REDUCE study

PURPOSE

Although the relationship between smoking and prostate cancer risk is inconsistent, some studies show that smoking is associated with prostate cancer mortality. Whether this reflects delayed diagnosis or direct smoking-related effects is unknown. REDUCE, which followed biopsy-negative men with protocol-dictated prostate-specific antigen (PSA)-independent biopsies at 2 and 4 years, provides an opportunity to evaluate smoking and prostate cancer diagnosis with minimal confounding from screening biases.

EXPERIMENTAL DESIGN

Logistic regression was conducted to test the association between smoking and cancer on the first on-study biopsy (no cancer, low-grade Gleason 4-6, high-grade Gleason 7-10) in REDUCE.

RESULTS

Of 6,240 men with complete data and ≥1 on-study biopsy, 2,937 (45.8%) never smoked, 929 (14.5%) were current smokers, and 2,554 (39.8%) were former smokers. Among men with negative first on-study biopsies, smokers were 36% less likely to receive a second on-study biopsy (P < 0.001). At first on-study biopsy, 941 (14.7%) men had cancer. Both current and former smoking were not significantly associated with either total or low-grade prostate cancer (all P > 0.36). Current (OR = 1.44, P = 0.028) but not former smokers (OR = 1.21, P = 0.12) were at increased risk of high-grade disease. On secondary analysis, there was an interaction between smoking and body mass index (BMI; Pinteraction = 0.017): current smokers with BMI ≤ 25 kg/m(2) had an increased risk of low-grade (OR = 1.54, P = 0.043) and high-grade disease (OR = 2.45, P = 0.002), with null associations for BMI ≥ 25 kg/m(2).

CONCLUSION

Among men with elevated PSA and negative pre-study biopsy in REDUCE, in which biopsies were largely PSA independent, smoking was unrelated to overall prostate cancer diagnosis but was associated with increased risk of high-grade prostate cancer.

Cigarette smoking is associated with an increased risk of biochemical disease recurrence, metastasis, castration-resistant prostate cancer, and mortality after radical prostatectomy: results from the SEARCH database

BACKGROUND

The current study was conducted to analyze the association between cigarette smoking and metastasis (the primary outcome) as well as time to biochemical disease recurrence (BCR), metastasis, castration-resistant prostate cancer (CRPC), and prostate cancer-specific and overall mortality (secondary outcomes) after radical prostatectomy among men from the Shared Equal Access Regional Cancer Hospital cohort.

METHODS

A retrospective analysis was performed of 1450 subjects for whom smoking status was available from preoperative notes. Analysis of baseline characteristics by smoking status was performed using the chi-square and rank sum tests. The association between smoking status and time to the event was analyzed using Kaplan-Meier plots, the log-rank test, and Cox and competing risk models.

RESULTS

A total of 549 men (33%) men were active smokers and 1121 (67%) were nonsmokers at the time of surgery. Current smokers were younger and had a lower body mass index, higher prostate-specific antigen level, and more extracapsular extension and seminal vesicle invasion (all P<.05). A total of 509 patients, 26 patients, 30 patients, 18 patients, and 217 patients, respectively, experienced BCR, metastasis, CRPC, prostate cancer-related death, and any-cause death over a median follow-up of 62 months, 75 months, 61 months, 78 months, and 78 months, respectively. After adjusting for preoperative features, active smoking was found to be associated with an increased risk of BCR (hazards ratio [HR], 1.25; P=.024), metastasis (HR, 2.64; P=.026), CRPC (HR, 2.62; P=.021), and overall mortality (HR, 2.14; P<.001). Similar results were noted after further adjustment for postoperative features, with the exception of BCR (HR, 1.10; P=.335), metastasis (HR, 2.51; P=.044), CRPC (HR, 2.67; P=.015), and death (HR, 2.03; P<.001).

CONCLUSIONS

Among patients undergoing radical prostatectomy, cigarette smoking was associated with an increased risk of metastasis. In addition, smoking was associated with a higher risk of BCR, CRPC, and overall mortality. If confirmed, these data suggest that smoking is a modifiable risk factor in patients with aggressive prostate cancer.

The effects of cigarette smoking on prostate-specific antigen in two different age groups

BACKGROUND

We investigate the effects of cigarette smoking on prostate-specific antigen (PSA) using 2 different age groups.

METHODS

The study was carried out between January 2007 and October 2011 with men; the 2 sets of age groups were: 25 to 35 years and 50 to 70 years old. The participants were divided into 4 groups. Of the 25 to 35 age range, smokers were Group 1, and non-smokers were Group 2; of the 50 to 70 age range, smokers were Group 3 and non-smokers Group 4. In addition, for the 50 to 70 age group, the International Prostate Symptom Score was completed, digital rectal examination was performed, and transabdominal prostate volume was measured. We wanted to see whether prostate-specific antigen (PSA) levels showed a difference between the 2 age groups.

RESULTS

There were 114 patients in Group 1, 82 in Group 2, 90 in Group 3, and 102 in Group 4. The mean PSA level was 0.7 ± 0.28 ng/mL for Group 1, and 0.6 ± 0.27 ng/mL for Group 2 (p = 0.27), and there was no statistically significant difference between the 2 groups. The mean PSA was 2.5 ± 1.8 ng/mL for Group 3, and 2.1 ± 2.0 ng/mL (p = 0.59) for Group 4, and there was no statistically significant difference between the these 2 age groups.

INTERPRETATION

Cigarette smoking effects various hormone levels. Different from previous studies, the PSA level was higher in smokers compared to nonsmokers, although it was not statistically significant. Our study is limited by the small numbers in our study groups and the lack of PSA velocity data.

How can I help myself? A critical review of modifiable behaviors, medications, and complementary alternative medicine for men receiving radiotherapy for prostate cancer

Men receiving radiation for prostate cancer frequently want to know what steps they can take to optimize their chance of cure and reduce their risk of side effects. A variety of modifiable behaviors, medications, and complementary alternative medicine interventions have been investigated in this regard. In this review, we summarize data on tobacco use, exercise, statins and aspirin, and vitamins. There is limited randomized data supporting any of the interventions and additional studies are needed before clinicians can confidently inform their patients regarding what steps to take to improve their outcomes.

Lifestyle and dietary factors in the prevention of lethal prostate cancer

The prevention of lethal prostate cancer is a critical public health challenge that would improve health and reduce suffering from this disease. In this review, we discuss the evidence surrounding specific lifestyle and dietary factors in the prevention of lethal prostate cancer. We present a summary of evidence for the following selected behavioral risk factors: obesity and weight change, physical activity, smoking, antioxidant intake, vitamin D and calcium, and coffee intake.

Outcome in early cervical cancer following pre-operative low dose rate brachytherapy: a ten-year follow up of 257 patients treated at a single institution

OBJECTIVE

To report the outcome of preoperative low dose rate uterovaginal brachytherapy (LDR-UVBT) followed by radical surgery in the treatment of early cervical carcinoma.

METHODS

257 patients treated at Institut Curie from 1985 to 2008 for cervical carcinoma less than 4cm (FIGO stages Ib1, IIA and IIB) were studied. Patients received preoperative LDR-UVBT followed by hysterectomy Piver II type, with pelvic lymph nodes dissection (PLND). Predictive factors for pathological response to brachytherapy were analyzed with logistic regression, as well as survival rates.

RESULTS

44% of patients had residual tumor, 4.3% of patients had parametrial invasion and 17.9% of patients had lymph node involvement. Predictive factors for an incomplete pathological response were: initial clinical tumor size 20mm (OR 2.1), pN1 (OR 2.77), glandular carcinoma (OR 2.51) and lymphovascular invasion (OR 4.35). 7.4% and 2.7% of patients had respectively grade 2 and grade 3 post-therapeutic late complications. Median follow up was 122 months [1-282]. Five-year actuarial overall survival and disease free survival were respectively 83% CI [78.3-87.5] and 80.9% CI [76.3-85.7]. In multivariate analysis, factors affecting significantly the overall survival and disease free survival rates were: lymph node involvement (RR 4.53 and 8.96 respectively), parametrial involvement (RR 5.69 and 5.62 respectively), smoking (RR 3.07 and 2.63 respectively).

CONCLUSIONS

Preoperative LDR-UVBT results in good disease control with a low complications rate. Its accuracy could be improved by a better selection of patients. Lymph nodes and parametrial evaluation remains a challenging issue that should be achieved with imaging and minimal invasive surgery.

Smoking and prostate cancer survival and recurrence

CONTEXT

Studies of smoking in relation to prostate cancer mortality or recurrence in prostate cancer patients are limited, with few prostate cancer-specific outcomes.

OBJECTIVE

To assess the relation of cigarette smoking and smoking cessation with overall, prostate cancer-specific, and cardiovascular disease (CVD) mortality and biochemical recurrence among men with prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

Prospective observational study of 5366 men diagnosed with prostate cancer between 1986 and 2006 in the Health Professionals Follow-Up Study.

MAIN OUTCOME MEASURES

Hazard ratios (HRs) for overall, prostate cancer-specific, and CVD mortality, and biochemical recurrence, defined by an increase in prostate-specific antigen (PSA) levels.

RESULTS

There were 1630 deaths, 524 (32%) due to prostate cancer and 416 (26%) to CVD, and 878 biochemical recurrences. Absolute crude rates for prostate cancer-specific death for never vs current smokers were 9.6 vs 15.3 per 1000 person-years; for all-cause mortality, the corresponding rates were 27.3 and 53.0 per 1000 person-years. In multivariable analysis, current vs never smokers had an increased risk of prostate cancer mortality (HR, 1.61; 95% confidence interval [CI], 1.11-2.32), as did current smokers with clinical stage T1 through T3 (HR, 1.80; 95% CI, 1.04-3.12). Current smokers also had increased risk of biochemical recurrence (HR, 1.61; 95% CI, 1.16-2.22), total mortality (HR, 2.28; 95% CI, 1.87-2.80), and CVD mortality (HR, 2.13; 95% CI, 1.39-3.26). After adjusting for clinical stage and grade (likely intermediates of the relation of smoking with prostate cancer recurrence and survival), current smokers had increased risk of prostate cancer mortality (HR, 1.38; 95% CI, 0.94-2.03), as did current smokers with clinical stage T1 through T3 (HR, 1.41; 95% CI, 0.80-2.49); they also had an increased risk of biochemical recurrence (HR, 1.47; 95% CI, 1.06-2.04). Greater number of pack-years was associated with significantly increased risk of prostate cancer mortality but not biochemical recurrence. Current smokers of 40 or more pack-years vs never smokers had increased prostate cancer mortality (HR, 1.82; 95% CI, 1.03-3.20) and biochemical recurrence (HR, 1.48; 95% CI, 0.88-2.48). Compared with current smokers, those who had quit smoking for 10 or more years (HR, 0.60; 95% CI, 0.42-0.87) or who have quit for less than 10 years but smoked less than 20 pack-years (HR, 0.64; 95% CI, 0.28-1.45) had prostate cancer mortality risks similar to never smokers (HR, 0.61; 95% CI, 0.42-0.88).

CONCLUSIONS

Smoking at the time of prostate cancer diagnosis is associated with increased overall and CVD mortality and prostate cancer-specific mortality and recurrence. Men who have quit for at least 10 years have prostate cancer-specific mortality risks similar to those who have never smoked.

Smoking and aggressive prostate cancer: a review of the epidemiologic evidence

Although tobacco use has been recognized as one of the leading causes of cancer morbidity and mortality, a role of smoking in the occurrence of prostate cancer has not been established. However, evidence indicates that factors that influence the incidence of prostate cancer may differ from those that influence progression and fatality from the disease. Thus, we reviewed and summarized results from prospective cohort studies that assessed the relation between smoking and fatal prostate cancer risk, as well as epidemiological and clinical studies that focused on aggressive behavior in prostate cancer, such as poorer survival, advanced stage, or poorer differentiation at diagnosis. The majority of the prospective cohort studies showed that current smoking is associated with a moderate increase of ~30% in fatal prostate cancer risk compared to never/non-smokers. This association is likely to be an underestimate of the effect of smoking because most studies had a single assessment of smoking at baseline and long follow-up times, and the association was considerably stronger in some sub-groups of heaviest smokers, or when smoking was assessed in a relatively short period (within 10 years) prior to cancer mortality. Using aggressive behavior of prostate cancer as outcome, current smoking was associated with significantly elevated risk, ranging from around twofold to threefold or higher. Although alternative explanations, such as publication bias, residual confounding, screening bias, and the influence of smoking-related comorbidities cannot be ruled out entirely, these findings suggest that smoking is associated with aggressive behavior of prostate cancers or with a sub-group of rapidly progressing prostate cancer. Based on evidence presented in this review, cigarette smoking is likely to be a risk factor for prostate cancer progression and should be considered as a relevant exposure in prostate cancer research and prevention of mortality from this cancer.

Cigarette smoking and prostate cancer recurrence after prostatectomy

Toward the establishment of evidence-based recommendations for the prevention of prostate cancer recurrence after treatment, we examined the association between smoking and prostate cancer recurrence in a retrospective cohort study of 1416 men who underwent radical prostatectomy. Surgeries were performed by a single surgeon at Johns Hopkins Hospital between January 1, 1993, and March 31, 2006. Smoking status at 5 years before and 1 year after surgery was assessed by survey. Prostate cancer recurrence was defined as confirmed re-elevation of prostate-specific antigen levels, local recurrence, metastasis, or prostate cancer death. The cumulative incidence of recurrence was 34.3% among current smokers, 14.8% among former smokers, and 12.1% among never smokers, with a mean follow-up time of 7.3 years. Men who were current smokers at 1 year after surgery were more likely than never smokers to have disease recurrence after adjusting for pathological characteristics, including stage and grade (hazard ratio for recurrence = 2.31, 95% confidence interval = 1.05 to 5.10). This result suggests an association between cigarette smoking and risk of prostate cancer recurrence.

Cigarette smoking and outcomes after allogeneic hematopoietic stem cell transplantation

Abnormal lung function is a known risk factor for poor outcomes in the allogeneic hematopoietic stem cell transplantation (HSCT) population, although the specific causes of these abnormalities have not been well explored. There is limited data on the effect of cigarette smoking on transplantation outcomes. We conducted a retrospective observational cohort study of 845 consecutive patients age ≥ 18 years who underwent allogeneic HSCT at the Seattle Cancer Care Alliance/Fred Hutchinson Cancer Research Center. Smoking exposure was defined by quit time, smoking status (never, former, and current), and log(2)-transformed pack-years. The main outcomes were time to respiratory failure within 100 days of transplantation, relapse, and nonrelapse mortality. In multivariable analyses, a 2-fold increase in pack-years smoked was associated with an increased risk of early respiratory failure (hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.09 to 1.64, P = .006). This association was observed independent of pretransplantation lung function. A 2-fold increase in pack-years smoked was associated with an increased risk of relapse, but this finding was not statistically significant (HR 1.16, 95% CI 0.92-1.46, P = .21). An association was not observed between cigarette smoking and nonrelapse mortality. Cigarette smoking is associated with an increased risk of respiratory failure and relapse within 100 days of allogeneic HSCT. The association with respiratory failure is mediated in part by abnormal lung function before transplantation and likely through other mechanisms as well. Given the adverse effects associated with cigarette smoking before transplantation, future studies should focus on obtaining accurate smoking histories, tracking prospective changes in smoking status, and assessing the benefits of tobacco cessation on outcomes in this population.

Association of GSTM1T1 genes with COPD and prostate cancer in north Indian population

The glutathione S-transferase (GST) family of enzymes is known to play a pivotal role in phase II of biotransformation of xenobiotics, environmental carcinogens and pharmacological drugs. The objective of the present study was to investigate the role of GSTM1 and GSTT1 null genotypes as risk factors for chronic obstructive pulmonary disease (COPD) and prostate cancer. The subjects appraised were 200 COPD cases, 150 prostate cancer cases, 150 benign prostatic hyperplasia (BPH) cases, 200 age matched controls for COPD and 172 age matched controls for prostate cancer. GSTM1 and GSTT1 null genotype was found to confer 2.5 (OR 2.45; 95% CI 1.56-3.82; P value = 0.00008) and 2.4-fold (OR 2.39; 95% CI 1.36-4.20; P value = 0.002) significant higher risk for prostate cancer. Smoking imparted a 2.2-fold significant risk of prostate cancer cases (OR 2.23; 95% CI 1.36-3.65 P value = 0.001) and twofold risk in BPH (OR 2.09; 95% CI 1.26-3.46; P value = 0.005). In case of COPD only null genotype of GSTT1 has shown 2.1-fold (OR 2.11; 95% CI 1.22-3.62; P value = 0.007) significant increased risk.

Association of cigarette smoking with interval to biochemical recurrence after radical prostatectomy: results from the SEARCH database

OBJECTIVES

To analyze the association between cigarette smoking and biochemical recurrence (BCR) after radical prostatectomy among men from the Shared Equal Access Regional Cancer Hospital (SEARCH) cohort.

METHODS

We performed a retrospective analysis of 1267 subjects from the SEARCH cohort treated from 1998 to 2008 with smoking status available from the preoperative notes. A comparison of the baseline patient and disease characteristics between the current smokers and nonsmokers (past and never smokers combined) was performed using the chi-square and rank sum tests. The univariate and multivariate associations between smoking status and BCR-free survival were analyzed using Kaplan-Meier plots, the log-rank test, and Cox proportional hazard models.

RESULTS

Of the 1267 patients, 408 (32%) were active smokers and 859 (68%) were nonsmokers at surgery. The current smokers were younger (P < .001), more likely to be black (P < .001), and had a lower body mass index (P < .001), a greater percentage of positive biopsy cores (P = .039), a greater preoperative prostate-specific antigen level (P = .003), more extracapsular extension (P = .003) and seminal vesicle invasion (P = .029), and lower prostate volumes (P = .002). On univariate analysis, smokers had a risk of BCR similar to that of nonsmokers (hazard ratio 1.19, P = .129). On multivariate analysis, smoking was associated with an increased risk of BCR when adjusted for body mass index only (hazard ratio 1.37, P = .008). However, after adjustment for multiple preoperative characteristics, the association was attenuated and no longer statistically significant (hazard ratio 1.12, P = .325). After additional adjustment for postoperative features, such as tumor grade and stage, smoking was unrelated to the risk of BCR (hazard ratio 0.91, P = .502).

CONCLUSIONS

Among patients undergoing radical prostatectomy in the SEARCH cohort, cigarette smoking was associated with slightly more advanced disease but a similar risk of BCR.

Who's assessing tobacco use in cancer clinical trials?

INTRODUCTION

Clinical trials that do not collect data on tobacco use/exposure may not adequately assess the efficacy and effectiveness of experimental treatments.

METHODS

A cross-sectional study of interventional trials cited on ClinicalTrials.gov was undertaken that inquired of Local Project Directors from Connecticut guiding studies of breast, prostate, or colorectal cancer chemotherapy (N = 68) whether their protocols measured tobacco use by trial participants. Information pertaining to 46 trials (68%) is reported here. All but 1 were multicentered trials enrolling patients around the country.

RESULTS

Only 3 trials (7%) reported routine collection of tobacco use information at baseline and no trial reported monitoring tobacco use during treatment follow-up. None of the 3 trials collecting tobacco data reported using exposure information in analysis of treatment effects. Survey respondents suggested that uncertainty about the relevance of tobacco exposure to therapeutic efficacy, ambivalence about how to incorporate such data into analyses, insufficient resources for collecting such information, and uncertainty about the validity of assessment methods might be reasons why tobacco use is not routinely assessed.

DISCUSSION

Additional studies that address a fuller range of cancers, therapies, disease states, and clinical environments are needed to fully define the extent of this data lapse. Providing clinicians and trialists with appropriate tools for tobacco use assessment and encouraging them to collect such information about patients during treatment and follow-up may offer a simple cost-effective way to improve the quality and consequences of cancer care for every patient.

Cigarette smoking and prostate cancer in a prospective US cohort study

Smoking is an important risk factor for many cancers, yet the relationship between smoking and prostate cancer remains uncertain. We investigated whether smoking affected the risk of prostate cancers within a large prospective cohort study of dietary and environmental cancer risk factors among men ages 50 to 71 upon enrollment in 1995-1996 (n = 283,312). Cox proportional hazards regression models with hazard ratios (HR) and 95% confidence intervals (95% CI) were adjusted for age, race, education, height, body mass index, physical activity, family history of prostate cancer, diabetes, self-reported health status, prostate-specific antigen testing, digital rectal exam, total energy, alpha-tocopherol, calcium, alpha-linolenic acid, selenium, red meat, fish, and tomato intake. There were 14,810 nonadvanced and 1,830 advanced incident prostate cancers identified through 2003, and 394 men died of their disease through 2005. Current smokers had a decreased risk of nonadvanced prostate cancer (HR, 0.82; 95% CI, 0.77-0.88), but an increased risk of fatal prostate cancer (HR, 1.69; 95% CI, 1.25-2.27). Former smoking was also associated with decreased risk of nonadvanced prostate cancers (HR, 0.89; 95% CI, 0.86-0.92), but not fatal prostate cancers (HR, 1.03; 95% CI, 0.83-1.27). There was no apparent association between smoking and advanced prostate cancer. A number of biologically plausible mechanisms could explain these results, including the direct effects of carcinogens in tobacco smoke and the resulting changes in sex hormone or growth factor profiles. These findings suggest that current and former smokers may be at decreased risk of being diagnosed with prostate cancer and current smokers are at an increased risk of dying from prostate cancer.

Evaluating localized prostate cancer and identifying candidates for focal therapy

Can focal therapy successfully control prostate cancer? Also, if so, which patients should be considered eligible? With limited data available from relatively few patients, these questions are difficult to answer. At this writing, the most likely candidates for focal therapy are patients with low-risk, small-volume tumors, located in 1 region or sector of the prostate, who would benefit from early intervention. The difficulty lies in reliably identifying these men. The larger number of cores obtained in each needle biopsy session has increased both the detection of prostate cancer and the potential risk of overtreating many patients whose cancers pose very little risk to life or health. Urologists typically perform at least a 12-core template biopsy. Although the debate continues about the optimal template, laterally and peripherally directed biopsies have been shown to improve the diagnostic yield. However, as many as 25% of tumors arise anteriorly and can be missed with peripherally directed techniques. Prostate cancer tends to be multifocal, even in its earliest stages. However, the secondary cancers are usually smaller and less aggressive than the index cancer. They appear similar to the incidental cancers found in cystoprostatectomy specimens and appear to have little effect on prognosis in surgical series. When a single focus of cancer is found in 1 core, physicians rightly suspect that more foci of cancer are present in the prostate. Assessing the risk in these patients is challenging when determined by the biopsy data alone. To predict the presence of a very low-risk or "indolent" cancer, nomograms have been developed to incorporate clinical stage, Gleason grade, prostate-specific antigen levels, and prostate volume, along with the quantitative analysis of the biopsy results. Transperineal "mapping" or "saturation" biopsies have been advocated to detect cancers missed or underestimated by previous transrectal biopsies. This approach could provide the accurate staging, grading, and tumor localization needed for a focal therapy program. Nevertheless, for men with minimal cancer who are amenable to active surveillance or focal therapy, consensus about the most accurate biopsy strategy has not yet been reached. Imaging, particularly magnetic resonance imaging and magnetic resonance spectroscopic imaging, has been used to assess men with early-stage prostate cancer. Large-volume cancers can be seen reasonably well, but small lesions have been difficult to detect reliably or measure accurately. Factors such as voxel resolution, organ movement, biopsy artifact, and benign changes have limited the consistent estimation of the quantitative tumor volume. Nevertheless, magnetic resonance imaging and magnetic resonance spectroscopic imaging can aid in evaluating patients with prostate cancer being considered for focal therapy by providing additional evidence that the patient does not harbor an otherwise undetected high-risk, aggressive cancer. In some cases, imaging can usefully identify the location of even a limited-sized index cancer. When imaging findings are substantiated by mapping biopsy results, confidence in the accurate characterization of the cancer is enhanced. Correlating the imaging results with tissue changes during and after treatment can be of use in monitoring the ablative effects in the prostate and in assessing for tumor recurrence. More work is necessary before staging studies can uniformly characterize a prostate cancer before therapy, much less reliably identify and locate small-volume cancer within the prostate. However, exploring the role of focal ablation as a therapeutic option for selected men with low-risk, clinically localized, prostate cancer need not await the emergence of perfectly accurate staging studies, any more than the application of radical surgery or radiotherapy have. Modern biopsy strategies, combined with optimal imaging and nomograms to estimate the pathologic stage and risk, taken together, provide a sound basis for the selection of appropriate patients for entry into prospective clinical trials of focal therapy.