Second primary tumors following tobacco dependence treatments among head and neck cancer patients

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

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

A Population-Level Assessment of Smoking Cessation following a Diagnosis of Tobacco- or Nontobacco-Related Cancer among United States Adults

Introduction

Smoking cessation after a cancer diagnosis can significantly improve treatment outcomes and reduce the risk of cancer recurrence and all-cause mortality.

Aim

We sought to measure the association between cancer diagnosis and subsequent smoking cessation.

Methods

Data was sourced from the Population Assessment of Health and Tobacco (PATH) study, a representative population-based sample of United States adults. Our analytic sample included all adult smokers at Wave I, our baseline. The exposure of interest was either a tobacco-related cancer diagnosis, nontobacco-related cancer diagnosis, or no cancer diagnosis (the referent) reported at Wave II or III. The primary outcome was smoking cessation after diagnosis, at Wave IV. Results/Findings. Our sample was composed of 7,286 adult smokers at the baseline representing an estimated 40.9 million persons. Smoking cessation rates after a diagnosis differed after a tobacco-related cancer (25.9%), a nontobacco-related cancer (8.9%), and no cancer diagnosis (17.9%). After adjustment, diagnosis with a tobacco-related cancer was associated with a higher odds of smoking cessation (OR 1.83, 95% CI 1.00-3.33) compared to no cancer diagnosis. Diagnosis with a nontobacco-related cancer was not significantly linked to smoking cessation (OR 0.52, 95% CI 0.48-1.45).

Conclusion

Diagnosis with a tobacco-related cancer is associated with greater odds of subsequent smoking cessation compared to no cancer diagnosis, suggesting that significant behavioral change may occur in this setting.

Association of Cigarette Use and Substance Use Disorders among US Adults with and without a Recent Diagnosis of Cancer

Background: Few studies have examined substance use disorders (SUDs) in cancer patients and it is unclear whether SUDs differentially impact cigarette smoking in patients with vs. without cancer. This study used epidemiological data to estimate current cigarette smoking prevalence and quit ratios among US adults with and without SUDs by cancer status. Methods: Data were drawn from the 2015–2018 National Survey on Drug Use and Health (n = 170,111). Weighted current smoking prevalence and quit ratios were estimated across survey years by SUDs (with vs. without) and by cancer status (with vs. without). Results: Among those with cancer, current smoking prevalence was higher for those with vs. without SUDs (47% vs. 13%, p < 0.001) and quit ratios lower for those with vs. without SUDs (45% vs. 71%, p = 0.002). A similar pattern was observed in adults without cancer, with higher smoking prevalence (56% vs. 21%, p < 0.001) and lower quit ratios (23% vs. 51%, p < 0.001) observed for those with vs. without SUDs, respectively. In adjusted logistic regressions, the SUD × cancer status interaction was not significant for smoking prevalence or quit ratios (AOR = 1.2; 95% CI: 0.7, 2.1, p = 0.56; AOR = 1.0; 95% CI: 0.5, 2.0, p = 0.91, respectively), though smoking prevalence was lower and quit ratios higher for adults with vs. without cancer (ps < 0.05). Conclusions: Among US adults with and without cancer, individuals with SUDs evidenced higher cigarette smoking and lower quit ratios than those without SUDs. Addressing SUDs and their impact on smoking cessation is critical in cancer patients with implications for improving health and treatment outcomes.

Prediagnosis and postdiagnosis smoking and survival following diagnosis with ovarian cancer

Little is known about the influence of prediagnosis and postdiagnosis smoking and smoking cessation on ovarian cancer survival. We investigated this relationship in two prospective cohort studies, the Nurses' Health Study (NHS) and NHSII. Analyses included 1,279 women with confirmed invasive, Stage I-III epithelial ovarian cancer. We used Cox proportional hazards regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ovarian cancer-specific mortality by smoking status, adjusting for age and year of diagnosis, tumor stage, histologic subtype, body mass index and nonsteroidal anti-inflammatory use (postdiagnosis models only). When examining prediagnosis smoking status (assessed a median of 12 months before diagnosis), risk of death was significantly increased for former smokers (HR = 1.19, 95% CI: 1.02-1.39), and suggestively for current smokers (HR = 1.21, 95% CI: 0.96-1.51) vs. never smokers. Longer smoking duration (≥20 years vs. never, HR = 1.23, 95% CI: 1.05-1.45) and higher pack-years (≥20 pack-years vs. never, HR = 1.28, 95% CI: 1.07-1.52) were also associated with worse outcome. With respect to postdiagnosis exposure, women who smoked ≥15 cigarettes per day after diagnosis (assessed a median of 11 months after diagnosis) had increased mortality compared to never smokers (HR = 2.34, 95% CI: 1.63-3.37). Those who continued smoking after diagnosis had 40% higher mortality (HR = 1.40, 95% CI: 1.05-1.87) compared to never smokers. Overall, our results suggest both prediagnosis and postdiagnosis smoking are associated with worse ovarian cancer outcomes.

The importance of incorporating smoking cessation into lung cancer screening

Lung cancer is the leading cause of cancer-related death in the United States (U.S.) and is the second most common non-skin cancer among men and women, accounting for about 30% of cancer-related deaths. There is clear and accumulating evidence that continued tobacco use has multiple adverse effects on cancer treatment outcomes, including greater probability of recurrence, second primary malignancies, reduced survival, greater symptom burden, and poorer quality of life (QOL). Recent findings suggest an avenue to significantly mitigate the impact of smoking on lung cancer mortality rates through the use of low-dose computed tomography (LDCT) lung cancer screening. Based on the reviewed evidence (type B), the U.S. Preventive Services Task Force (USPSTF) guidelines of 2015 recommend screening combined with smoking cessation interventions for high-risk heavy smokers and recent quitters. These practice changes offer opportunities to develop novel smoking cessation strategies tailored to highly specific settings that aim to amplify the survivorship gains expected from screening alone. However, there is a paucity of research and data that speaks to the feasibility and efficacy of providing smoking cessation treatment specifically within the context of the LDCT lung cancer screening environment. While some studies have attempted to characterize the parameters within which smoking cessation interventions should be implemented in this context, further research is needed to explore relevant factors such as the format, components, and timing of interventions, as well as the influence of risk perceptions and results of the screening itself on motivation and ability to quit smoking.

Tumour stage and gender predict recurrence and second primary malignancies in head and neck cancer: a multicentre study within the INHANCE consortium

Recurrence and second primary cancer (SPC) continue to represent major obstacles to long-term survival in head and neck cancer (HNC). Our aim was to evaluate whether established demographics, lifestyle-related risk factors for HNC and clinical data are associated with recurrence and SPC in HNC. We conducted a multicentre study by using data from five studies members of the International Head and Neck Cancer Epidemiology consortium—Milan, Rome, Western Europe, Sao Paulo, and Japan, totalling 4005 HNC cases with a median age of 59 (interquartile range 52–67). Multivariate hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for recurrence and SPC. During follow-up, 1161 (29%) patients had recurrence and 343 (8.6%) developed SPC. Advanced tumour stage was associated with increased risk of recurrence in HNC overall (HR = 1.76, 95% CI 1.41–2.19). Women with laryngeal cancer had a reduced risk of recurrence compared to men (HR = 0.39, 95% CI: 0.24–0.74). Concerning predictors of SPC, advanced age (HR = 1.02; 95% CI: 1.00–1.04) and alcohol consumption (> 1 drink per day, HR = 2.11; 95% CI: 1.13–3.94) increased the risk of SPC among patients with laryngeal cancer. Additionally, women were at higher risk of SPC, in HNC overall group (HR = 1.68; 95% CI: 1.13–2.51) and oropharyngeal cancer group (HR = 1.74; 95% CI: 1.02–2.98). Tumour stage and male gender (larynx only) were positive predictors of cancer recurrence in HNC patients. Predictors of SPC were advanced age and alcohol use among laryngeal cancer cases, and female gender for oropharyngeal and HNC overall.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Stigmatic and Sympathetic Attitudes Toward Cancer Patients Who Smoke: A Qualitative Analysis of an Online Discussion Board Forum

INTRODUCTION

A significant minority of patients continue to smoke after a cancer diagnosis. Cancer patients who smoke experience stigma that can negatively impact health outcomes. We explored publicly shared perspectives about cancer patients who continued to smoke post-diagnosis.

METHODS

An online news article, published in January 2012, summarized the findings of smoking prevalence among patients with lung cancer and colorectal cancer enrolled in the Cancer Care Outcomes Research and Surveillance Consortium trial. In response, written comments were posted on the articles' public discussion board. Applying principles of grounded theory, we conducted a document analysis and established a conceptual framework to develop a model by which to explain factors underlying stigmatic and sympathetic attitudes toward cancer survivors who continue to smoke.

RESULTS

Personal experiences with cancer, smoking, and statistical literacy were found to influence beliefs about cancer and smoking, which in turn influenced stigmatic or sympathetic attitudes. More sympathetic attitudes were expressed by individuals who had personal experiences with smoking, believed cancer is multicausal, identified smoking as an addiction, or considered extrinsic factors responsible for smoking. Individuals who did not have personal experiences with cancer or smoking, had low statistical literacy, believed that smoking necessarily and directly causes cancer, and focused on intrinsic responsibilities for smoking tended to express more stigmatic attitudes.

CONCLUSIONS

The current findings raise awareness and provide insight into stigma against cancer survivors who smoke and can help inform strategies for reducing stigma against this vulnerable group.

IMPLICATIONS

This study helps raise awareness of stigma toward cancer patients who smoke and provides insight into the processes that may influence stigmatic as compared to sympathetic attitudes toward these patients. Results suggest that population-based strategies to educate the public regarding the nature of nicotine addiction, difficulty of quitting, and benefits of quitting for cancer patients may be useful for reducing stigma against cancer patients with a smoking history.

Integrating tobacco treatment into thoracic oncology settings: Lessons learned

Clinical practice guidelines recommend tobacco treatment for all cancer patients. However, little is known about how to integrate tobacco treatment into cancer care. The results of our pilot study of an evidence-based tobacco treatment integrated into a thoracic oncology clinic demonstrated good feasibility and efficacy, providing an opportunity to inform future tobacco treatment integration efforts. Here, we describe the process of intervention development, clinic integration, patient identification, and patient enrollment. We report on the intervention content and delivery, patterns of quitting for participants in the tobacco treatment group, and changes in smoking-related psychosocial variables. Clinical implications and suggestions for future research are discussed.

Informational and Support Needs of Patients with Head and Neck Cancer: Current Status and Emerging Issues

The objective of this article is to review and summarize the extant literature on head and neck cancer (HNC) patients’ informational needs and to characterize emerging issues in this patient population in order to define priorities for future research. HNC patients may undergo challenging treatment regimens and experience treatment-related alterations in primary daily functions such as speech and eating. These changes often persist following treatment and may lead to significant deficits in quality of life and interpersonal relations. Despite empirical evidence demonstrating that receipt of adequate information and support is predictive of improved outcomes post-treatment, relatively limited attention has been paid to the informational and support needs of HNC patients. This review focuses primarily on three topic domains: (1) managing treatment-related side effects; (2) addressing alcohol and tobacco dependence; and (3) informational needs in the areas of human papillomavirus (HPV) and clinical trials. While there is increasing awareness of the rehabilitation and survivorship needs in this patient population, patients note that the impact of treatment on social activities and interactions is under-discussed and of key concern. In addition, there is a significant gap in addressing communication and informational needs of caregivers and family members who are integral for promoting healthy behaviors and self-care post-treatment. Greater integration of programs that address tobacco or alcohol dependency within a comprehensive treatment and support plan may increase patient motivation to seek help and enhance patient success in maintaining long-term abstinence. Finally, emerging patient-provider communication needs, particularly in the context of decision making about clinical trials or surrounding an HPV-related diagnosis, have been noted among both patients and healthcare providers. Future research on the development of novel programs that offer feasible and acceptable methods for addressing unmet informational and support needs is warranted and may yield benefit for improving patient-reported outcomes.

Integrating tobacco treatment into cancer care: Study protocol for a randomized controlled comparative effectiveness trial

BACKGROUND

Despite the well-established risks of persistent smoking, 10-30% of cancer patients continue to smoke after diagnosis. Evidence-based tobacco treatment has yet to be integrated into routine oncology care. This paper describes the protocol, manualized treatment, evaluation plan, and overall study design of comparing the effectiveness and cost of two treatments across two major cancer centers.

METHODS/DESIGN

A two-arm, two-site randomized controlled comparative effectiveness trial is testing the hypothesis that an Intensive Treatment (IT) intervention is more effective than a Standard Treatment (ST) intervention in helping recently diagnosed cancer patients quit smoking. Both interventions include 4 weekly counseling sessions and FDA-approved smoking cessation medication advice. The IT includes an additional 4 biweekly and 3 monthly booster sessions as well as dispensal of the recommended FDA-approved smoking cessation medication at no cost. The trial is enrolling patients with suspected or newly diagnosed cancer who have smoked a cigarette in the past 30days. Participants are randomly assigned to receive the ST or IT condition. Tobacco cessation outcomes are assessed at 3 and 6months. The primary study outcome is 7-day point prevalence biochemically-validated tobacco abstinence. Secondary study outcomes include the incremental cost-effectiveness of the IT vs. ST.

DISCUSSION

This trial will answer key questions about delivering tobacco treatment interventions to newly diagnosed cancer patients. If found to be efficacious and cost-effective, this treatment will serve as a model to be integrated into oncology care settings nation-wide, as we strive to improve treatment outcomes and quality of life for cancer patients.

The effects of hemoglobin levels and their interactions with cigarette smoking on survival in nasopharyngeal carcinoma patients

There is very little published information regarding the prognostic value of hemoglobin (Hb) levels combined with smoking on the survival of patients with nasopharyngeal carcinoma (NPC), and the interactions between them remain unclear. A total of 2440 NPC patients were confirmed, and multivariate analysis was performed to identify valuable prognostic Hb levels in the entire population and in the cohort of smokers. The survival differences were compared using log‐rank tests. The multiplicative and additive interactions were assessed using Cox regression and a Microsoft Word Excel spreadsheet. Postradiotherapy (RT) Hb was an independent prognostic factor for overall survival (OS) (HR = 0.797; P = 0.006), failure‐free survival (FFS) (HR=0.811; P = 0.010), and loco‐regional failure‐free survival (LR‐FFS) (HR = 0.725; P = 0.000). In the cohort of smokers, pack‐years was also an independent predictor of OS (HR = 0.673; P < 0.001) and FFS (HR = 0.681; P < 0.001), LR‐FFS (HR = 0.663; P = 0.001). A significant positive additive effect was found for the interaction between low post‐RT Hb and high SI on OS, with RERI = 5.616, AP = 0.665, and S = 4.078. Stratified analyses demonstrated that heavy smokers with low post‐RT Hb had HRs of 2.295 (P < 0.001) for death, 2.222 (P < 0.001) for disease failure, and 2.267 (P < 0.001) loco‐regional recurrence compared with light smokers with high post‐RT Hb levels, and post‐RT Hb level is an important predictor of survival in patients with NPC. The positive interaction between post‐RT Hb level and pack‐years contributes to the elevated risk of poor survival. Oncologists should devote particular attention to heavy smokers with low post‐RT Hb levels in the future.

Factors That Predict Persistent Smoking of Cancer Survivors

We conducted this cross-sectional study to elucidate factors that predict persistent smoking of the Korean cancer survivors. The subjects were 130 adult (≥19 yr old) cancer survivors who were smokers at the diagnosis of cancer and have participated in the Korean National Health and Nutrition Examination Surveys conducted from 2007 to 2011. We categorized them into the persistent smokers and the quitters, according to change in smoking status between the time of cancer diagnosis and the time of the survey. Factors associated with persistent smoking were evaluated using the multiple logistic regression analysis. During 7.52 yr (standard deviation = 0.34) after the cancer diagnosis, 59.6% of the 130 cancer survivors have continued to smoke. After adjusting for covariates, following factors were independently associated with the risk of persistent smoking: female, low income, high-risk alcohol use, high body mass index (≥ 25 kg/m(2)), presence of household members who smoke, and longer duration of smoking. Alcohol Use Disorders Identification Test showed a positive association with the risk of persistent smoking (P for trend = 0.012). In conclusion, more efforts for smoking cessation should be in place for the cancer survivors with those risk factors associated with the persistent smoking.

Smoking cessation treatment and outcomes in medium to heavy cigarette smokers being treated for cancer in Jordan

BACKGROUND

Studies evaluating smoking cessation treatment outcomes in cancer patients are scarce, despite smoking cessation importance in cancer care. We sought to add to the literature by evaluating smoking cessation in a challenging group of cancer patients (medium-to-heavy smokers) visiting an out-patient smoking cessation clinic (SCC) in a cancer center in Amman, Jordan.

MATERIALS AND METHODS

Patients smoking >9 cigarettes per day (CPD) and referred to the SCC between June 2009 and May 2012 were studied. Clinic records were reviewed to measure demographic and baseline clinical characteristics, and longitudinal (3-, 6- and 12- month) follow- up by phone/clinic visit was conducted. At each follow-up, patients were asked if they experienced medication side-effects, if they had returned to smoking, and reasons for failing to abstain. Descriptive and multivariable logistic regression analyses were performed.

RESULTS

A total of 201 smokers were included in the analysis. The 3-month abstinence was 23.4% and significantly associated with older age, being married, and presenting with lower (≤ 10 ppm) baseline carbon monoxide (CO) levels. On a multivariable level, lower CO levels, a higher income (relative to the lowest income group), being older, and reporting severe dependence (relative to dependence reported as 'somewhat' or 'not') were significant predictors of higher odds of abstinence at three months. Reasons for failing to quit included not being able to handle withdrawal and seeing no value in quitting. Long- term ARs did not reach 7%.

CONCLUSIONS

In a sample of Jordanian smokers (>9CPD) with cancer and receiving smoking cessation treatment, ARs were low and further declined with time. Results underscore the need for more aggressive patient management and rigorous follow-up during and after smoking cessation treatment, particularly when this takes place in challenging settings. Observed reasons for failure to abstain should be used to tailor counseling practices.

National cancer institute conference on treating tobacco dependence at cancer centers

The National Cancer Institute cancer centers possess the credibility to help smokers quit. With the greater life expectancies forecast for patients with cancer, addressing smoking at cancer centers has taken on greater importance.

Smoking Cessation Interventions and Cessation Rates in the Oncology Population

Objectives

To evaluate tobacco smoking cessation interventions and cessation rates in the oncology population through a systematic review and meta-analysis.

Data Sources

The literature was searched using PubMed, Google Scholar, Medline, EMBASE, and the Cochrane Library (inception to October 2012) by 3 independent review authors.

Review Methods

Studies were included if they were randomized controlled trials (RCTs) or prospective cohort (PCs) studies evaluating tobacco smoking cessation interventions with patients assigned to a usual care or an intervention group. The primary outcome measure was smoking cessation rates. Two authors extracted data independently for each study. When applicable, disagreements were resolved by consensus.

Results

The systematic review identified 10 RCTs and 3 PCs. Statistical analysis was conducted using StatsDirect software (Cheshire, UK). Pooled odds ratios (ORs) for smoking cessation interventions were calculated in 2 groups based on follow-up duration. The therapeutic interventions included counseling, nicotine replacement therapy, buproprion, and varenicline. Smoking cessation interventions had a pooled odds ratio of 1.54 (95% confidence interval [CI], 0.909-2.64) for patients in the shorter follow-up group and 1.31 (95% CI, 0.931-1.84) in the longer follow-up group. Smoking cessation interventions in the perioperative period had a pooled odds ratio of 2.31 (95% CI, 1.32-4.07).

Conclusion

Our systematic review and meta-analysis demonstrate that tobacco cessation interventions in the oncology population, in both the short-term and long-term follow-up groups, do not significantly affect cessation rates. The perioperative period, though, may represent an important teachable moment with regard to smoking cessation.

[Laryngeal carcinoma: epidemiology, risk factors and survival]

Laryngeal cancer is one of the most frequent types of head and neck cancer. The incidence is decreasing for men but still increasing for women. The incidence in Germany is about 5-7/100,000 persons/year for men and 0.6-0.8/100,000 persons/year for women. Due to the increased life expectancy, the average age of patients diagnosed with laryngeal cancer is increasing. Nevertheless, adequately prepared older patients treated by standard protocols can have the same survival and complication rates as younger patients. Tobacco and alcohol are still the primary risk factors responsible for disease in at least 80% of the patients. Despite the many new diagnostic tools, still more than half of the patients are diagnosed at an advanced tumor stage. Survival rates have not improved significantly in the last 10 years in Germany, and the average 5-year overall survival rate is about 60%. However, a decrease in the survival rate, as observed in the USA, cannot be confirmed for Germany.

Importance of hemoglobin concentration and its modification for the outcome of head and neck cancer patients treated with radiotherapy

INTRODUCTION

Hypoxia induced radioresistance has been acknowledged for decades. One of the indirect evidences of the influence of hypoxia on radiation response comes from the observations of a correlation between tumor control and hemoglobin level. This review examines the clinical data on the prognostic and predictive role of hemoglobin level and hemoglobin manipulation in radiotherapy of squamous cell carcinomas of the head and neck, a tumor type where hypoxic radioresistance have been previously documented.

THE INFLUENCE OF HEMOGLOBIN CONCENTRATION ON TUMOR OXYGENATION AND OUTCOME

The aim is to evaluate the existing literature for information of the influence of hemoglobin concentration and hemoglobin modifications on tumor oxygenation and outcome in head and neck squamous cell cancer patients. The data from several randomized trials show that while most studies have confirmed the prognostic value of hemoglobin, increasing the hemoglobin level through transfusion or erythropoietin stimulation did not result in improved outcome for patients with low initial hemoglobin levels. Clinical studies showed that smoking reduced the oxygen carrying capacity of the blood through formation of carboxyhemoglobin, and lead to poorer response to radiotherapy in smokers compared to non-smokers. Smoking also increased the risk of the development of secondary cancers.

CONCLUSION AND FUTURE PERSPECTIVES

In conclusion, low hemoglobin is a significant negative prognostic factor for radiotherapy of head and neck cancer. Correction of pre-treatment low hemoglobin by blood transfusion and/or erythropoietin stimulating agents does, however, not improve the outcome. Smoking leads to a decrease in effective hemoglobin and poorer treatment outcome. Smoking should be avoided in order to improve the therapeutic efficacy of radiotherapy and development of other smoking-related diseases and/or secondary cancers.

Effect of smoking on oxygen delivery and outcome in patients treated with radiotherapy for head and neck squamous cell carcinoma--a prospective study

BACKGROUND

Head and neck cancer patients with high hemoglobin respond better to irradiation compared to patients with low hemoglobin possibly due to hypoxia induced radioresistance. The hemoglobin level is, however, a crude indicator of the amount of oxygen available to the tissue and may be influenced by a number of factors, smoking being of potential importance. The aim of the present study was to examine the effect of smoking on available oxygen to tumors and the effect on outcome in head and neck cancer patients treated with radiotherapy in a prospective study.

MATERIALS AND METHODS

A total of 232 consecutive patients with squamous cell carcinoma of the larynx, pharynx and oral cavity completed questionnaires on smoking habits prior to treatment. Venous blood samples were collected before and/or during treatment to determine the hemoglobin and carboxyhemoglobin level. Patients were treated with primary curative radiotherapy 62-68 Gy, 2 Gy/fx, 5 fx/week.

RESULTS

All but 12 patients had a history of smoking, 35 were long term quitters, 23 recent quitters, 54 moderate smokers and 108 heavy smokers (>1 pack/day). There was no relationship between total hemoglobin and carboxyhemoglobin, but effective hemoglobin and carboxyhemoglobin were linearly correlated. The amount of carboxyhemoglobin increased with increasing smoking status. Actuarial 5-year univariate analysis showed that heavy smokers had a significantly reduced probability of loco-regional control (44% vs. 65%, p = 0.001), disease-specific (56% vs. 77%, p = 0.003) and overall survival (39% vs. 66%, p = 0.0004) compared to non-smoking patients. Multivariate analyses showed that patients characterized as non-smokers, with low T and N classifications and high hemoglobin level had the best outcome measurements. A rise in carboxyhemoglobin significantly decreased the probability of loco-regional control and each additional pack year increased the risk of death. Smokers and former smokers develop secondary cancers.

CONCLUSION

The study showed a significant negative impact of smoking during radiotherapy for head and neck cancer and the risk of death was increased with each additional pack year of smoking. The effect on loco-regional control could be explained by a rise in carboxyhemoglobin level in smokers, e.g. a reduced oxygen supply to tumors. The data strongly advocate that smoking should be avoided in order to improve the therapeutic efficacy of radiotherapy and development of other smoking-related diseases and/or secondary cancers.

Tobacco and alcohol use after head and neck cancer treatment: influence of the type of oncological treatment employed

OBJECTIVE

To assess the cigarette smoking and alcohol intake maintenance rate in patients treated for head and neck squamous cell carcinoma and to compare the observed outcome with the type of oncological treatment employed.

METHODS

One hundred and ten patients treated for high aero-digestive tract squamous cell carcinoma were included and divided into a surgical group, treated with a surgery, and a medical group, treated with chemotherapy and/or radiation. The patients were interviewed to determine whether or not they had persisted with the smoking and drinking behavior after treatment. The habit maintenance rate was compared with the treatment modality employed. The relationship between the oncological status of the patients and the cigarette smoking and alcohol intake rates found was also tested.

RESULTS

Among smokers, 35% maintained the habit after treatment. The medical group had a significantly higher percentage of patients maintaining smoking compared with the surgical group (58.3% vs 25.0%; p = 0.004). Among alcohol users, 16.6% kept drinking alcoholic beverages, with a percentage also shown higher for the medical group (23.8% vs 13,3%), but with no statistically significant difference. The oncological status of patients was not related to the maintenance of the habits studied.

CONCLUSION

Smoking and alcoholism maintenance rates are high after head and neck squamous cell carcinoma is treated, especially if we consider smoking in patients treated with chemotherapy and/or radiation. A more effective multidisciplinary approach is required in order to obtain better rates of tobacco and alcohol quitting, especially in patients undergoing non-surgical treatments.

A snapshot of smokers after lung and colorectal cancer diagnosis

BACKGROUND

Continued smoking after a cancer diagnosis may adversely affect treatment effectiveness, subsequent cancer risk, and survival. The prevalence of continued smoking after cancer diagnosis is understudied.

METHODS

In the multi-regional Cancer Care Outcomes Research and Surveillance cohort (lung cancer [N = 2456], colorectal cancer [N = 3063]), the authors examined smoking rates at diagnosis and 5 months after diagnosis and also study factors associated with continued smoking.

RESULTS

Overall, 90.2% of patients with lung cancer and 54.8% of patients with colorectal cancer reported ever smoking. At diagnosis, 38.7% of patients with lung cancer and 13.7% of patients with colorectal cancer were smoking; whereas, 5 months after diagnosis, 14.2% of patients with lung cancer and 9.0% of patients with colorectal cancer were smoking. Factors that were associated independently with continued smoking among patients with nonmetastatic lung cancer were coverage by Medicare, other public/unspecified insurance, not receiving chemotherapy, not undergoing surgery, prior cardiovascular disease, lower body mass index, lower emotional support, and higher daily ever-smoking rates (all P < .05). Factors that were associated independently with continued smoking among patients with nonmetastatic colorectal cancer were male sex, high school education, being uninsured, not undergoing surgery, and higher daily ever-smoking rates (all P < .05).

CONCLUSIONS

After diagnosis, a substantial minority of patients with lung and colorectal cancers continued smoking. Patients with lung cancer had higher rates of smoking at diagnosis and after diagnosis; whereas patients with colorectal cancer were less likely to quit smoking after diagnosis. Factors that were associated with continued smoking differed between lung and colorectal cancer patients. Future smoking-cessation efforts should examine differences by cancer type, particularly when comparing cancers for which smoking is a well established risk factor versus cancers for which it is not.

Distinct features of second primary malignancies in head and neck cancer patients in Japan

Second primary malignancies (SPMs) are one of the most critical problems in treating head and neck cancer patients. Our hospital had 742 patients with a diagnosis of malignant head and neck tumors during the five-year period from 2002 to 2006. In this study, we analyzed 360 of those patients who were assumed to have risk factors such as alcohol and tobacco use: 106 oral, 120 laryngeal, 50 oropharyngeal and 84 hypopharyngeal cancer patients. Synchronous SPMs are defined as second cancers diagnosed at the same time or within 6 months of the diagnosis of the index head and neck cancers. There were 4 (3.8%) and 11 (10.4%) oral cancer patients, 11 (8.3%) and 8 (5.8%) laryngeal cancer patients, 7 (14.0%) and 4 (8.0%) oropharyngeal cancer patients, and 30 (28.6%) and 7 (8.3%) hypopharyngeal cancer patients with synchronous and metachronous SPMs, respectively. The number of metachronous patients with synchronous SPMs tended to increase during this time period. The frequencies of SPMs in oropharyngeal and hypopharyngeal cancer patients are similar to those in oral and laryngeal cancer patients. Notably, the most frequent SPMs are upper gastrointestinal tract cancers in Japan, compared to lung cancers in Europe. The five-year overall survival rate of patients with synchronous SPMs was significantly poorer than that of patients without any other tumor except for the index cancer, according to the Kaplan-Meier analysis. In conclusion, searching for SPMs in the upper gastrointestinal tract is a critical issue in head and neck cancer patients in Japan.

Correlates of continued tobacco use and intention to quit smoking among Russian cancer patients

BACKGROUND

Tobacco use among cancer patients is associated with adverse health outcomes. Little attention has been paid to tobacco use among cancer patients in developing countries, including Russia, where tobacco use is extremely high, and there is little public health infrastructure to address this issue.

PURPOSE

This study examined medical, socio-demographic, and psychological correlates of smoking status and intention to quit smoking among newly diagnosed Russian cancer patients.

METHOD

A cross-sectional study was conducted with 294 current or former smokers newly diagnosed with cancer.

RESULTS

Compared with patients who quit smoking, patients who continued to smoke were more likely to report urges to smoke to satisfy positive reinforcing aspects of tobacco use. Compared with patients who were smoking and reported no intention to quit smoking in the next 3 months, patients who were smoking but intended to quit smoking reported higher levels of perceived risks associated with continued smoking and higher levels of self-efficacy to quit smoking.

CONCLUSION

As commitment to developing smoking cessation treatment programs for cancer patients in Russia emerges, these data can help guide the development of behavioral interventions to assist patients with quitting smoking, enhancing their chances for improved clinical outcomes.

A smoking cessation intervention for thoracic surgery and oncology clinics: a pilot trial

INTRODUCTION

Although most smokers diagnosed with lung cancer report that they want to quit smoking, many do not succeed. Smokers who quit when lung cancer is diagnosed have improved treatment efficacy, quality of life, and survival. Effective smoking cessation interventions targeted to thoracic oncology patients are needed.

METHODS

This pilot study examined the feasibility and potential efficacy of a 12-week program that combined smoking cessation counseling with varenicline. Seven-day point prevalence tobacco abstinence rates at the end of treatment were compared with a usual care control group. From January 2008 to August 2009, patients with a diagnosed or suspected thoracic malignancy were recruited at their initial visit to a thoracic surgeon or thoracic oncologist at Massachusetts General Hospital.

RESULTS

Of 1130 patients screened, 187 (17%) were current smokers, and an additional 66 (6%) reported quitting within the past 6 months. One hundred sixteen (67%) of smokers were eligible, and 49 (42%) of eligible smokers enrolled (control group n = 17, intervention group n = 32). Intervention participants completed a median of nine counseling sessions; 50% of intervention participants completed the full varenicline course. At 12-week follow-up, biochemically validated 7-day point prevalence tobacco abstinence rates were 34.4% in the intervention group versus 14.3% in the control group (odds ratio = 3.14, 95% confidence interval = 0.59-16.62, p = 0.18).

CONCLUSION

Our findings support the feasibility and acceptability of this program. At the end of treatment, quit rates were higher in the intervention [corrected] group. Further testing is indicated to establish the efficacy of this treatment package in a randomized clinical trial.

Disparities between blacks and whites in tobacco and lung cancer treatment

Racial disparities exist in lung cancer incidence, morbidity, and mortality. Smoking is responsible for the majority of lung cancers, and racial disparities also exist in smoking outcomes. Black smokers are less likely than white smokers to engage in evidence-based tobacco treatment, and black smokers are less likely than white smokers to stop smoking. Continued smoking following a lung cancer diagnosis is a potential indicator of poor lung cancer treatment outcomes, yet lung cancer patients who smoke are unlikely to receive evidence-based tobacco treatment. The risks from continued smoking after diagnosis deserve attention as a modifiable factor toward lessening racial disparities in lung cancer outcomes.

Association between the STin2 VNTR polymorphism and smoking behavior in oral cancer patients and healthy individuals

The serotonergic system may be involved in smoking behavior since the intake of nicotine increases serotonin secretion in the CNS. Moreover, evidence supporting the beneficial effect of selective serotonin reuptake for quitting smoking suggesting that the serotonin transporter (5-HTT) is a plausible target for the understanding and elucidation of smoking behavior. The transcriptional activity of its human gene (SLC6A4) is modulated by a polymorphism described in the second intron, the STin2 VNTR, which thus may interfere with 5-HTT synthesis. In this study was analyzed the polymorphism STin2 VNTR of 60 smokers male patients diagnosed for oral carcinoma, 61 male smokers without cancer and 65 non-smoker healthy blood donors. The STin2. 9 allele carriers were more present in smoker groups (with cancer and without cancer, respectively) than in the non-smoker (OR = 7.11, 95% CI = 0.83-60.91 and OR = 24.73; IC 95% = 3.17-192.66). Conversely, individuals carrying allele 10 were more prevalent in non-smokers compared with smokers (oral cancer patients and individuals without cancer, respectively), showing a protective factor of this allele (OR = 0.56; 95% CI = 0.24-1.33 and OR = 0.46; 95% CI = 0.20-1.07). This is the first report of a study assessing the importance of STin2 VNTR smoking behavior in Brazilian individuals and the association of STin2. 9 allele carriers in nicotine dependence. It is suggested that individuals with low serotonin concentration in the central nervous system, probably due to the presence of the allele for high expression of 5-HTT,especially STin2. 9, were more susceptible to nicotine dependence. Moreover, individuals with the 10 allele might have less risk for nicotine dependence.

A bupropion smoking cessation clinical trial for cancer patients

OBJECTIVE

Many cancer patients continue to smoke post diagnosis, yet there have been few smoking cessation trials for this population. Depression, which is prevalent among cancer patients, may be a barrier to cessation.

METHODS

This double-blind placebo-controlled trial randomized 246 cancer patients to 9 weeks of placebo or bupropion, stratifying by pre-treatment depression symptoms. In addition, all patients received transdermal nicotine and behavioral counseling. Primary outcomes were 7-day point-prevalence abstinence, biochemically confirmed, at the end of treatment (Week 12), and at 6 months post quit day (Week 27). Additional outcomes included: withdrawal, affect, quality of life, compliance, and side effects.

RESULTS

There was no main effect of bupropion vs. placebo on abstinence (Odds Ratio [OR] = 1.36, 95% CI: 0.38-4.81, p = .64). Patients with depression symptoms reported significantly lower abstinence rates vs. patients without depression symptoms (OR = .14, 95% CI: 0.02-0.80, p = .03). Bupropion increased abstinence rates, vs. placebo, more for participants with depression vs. those without depression symptoms. For patients with depression symptoms, bupropion reduced withdrawal symptoms and improved quality of life vs. placebo.

CONCLUSIONS

For patients with depression symptoms, bupropion increases abstinence rates, lowers withdrawal, and increases quality of life. However, abstinence rates among patients with depression symptoms were low vs. patients without depression symptoms, who exhibited similar abstinence rates when treated with bupropion or transdermal nicotine and counseling alone. These results can guide future smoking cessation intervention studies with cancer patients.

A Challenging Picture of Cancer-and Inflammation-Related Changes

The authors describe a diagnostically challenging case where a patient with previous squamous cell carcinoma of the tonsil developed a putative second primary squamous cell carcinoma in the lung (stage IV with lung and bone metastases). During palliative chemotherapy several episodes of severe infection occurred, eventually resulting in abscess formation in the hip and brain. The dilemma of distinguishing between metastasis and abscess and the therapeutic implications are discussed.

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

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