Tobacco Cessation May Improve Lung Cancer Patient Survival

Effectiveness of a computer-facilitated intervention on improving provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting: A pilot study

INTRODUCTION

Effective tobacco treatments are available but are often not delivered to individuals with an actual or potential diagnosis of thoracic malignancy. The specific aims of this study were to identify the prevalence of tobacco use and examine the effectiveness of the Clinical and community Effort Against Smoking and secondhand smoke Exposure (CEASE), a system-level computer-facilitated intervention, to improve provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting.

METHODS

A pre-post-test design was used to assess the effectiveness of CEASE. A 3-step approach was used to integrate tobacco treatment into routine care: ask about tobacco use, assist with cessation, and refer to a quitline. An end-of-visit survey was conducted to collect prevalence of tobacco use and delivery of tobacco treatment. Descriptive statistics and Fisher's exact test were used for analysis.

RESULTS

A total of 218 individuals were enrolled; 105 participants were in usual care (UC) and 113 were in the CEASE group. Of those who enrolled, 27.6% were never smokers in UC and 27.7% in CEASE, 60% were former smokers in UC and 50% in CEASE, and 12.4% were current smokers in UC and 21.4% in CEASE. Significant differences were noted in delivery of tobacco treatment with 15.4% having received tobacco treatment in UC compared to 62.5% in CEASE (p<0.004).

CONCLUSIONS

A computer-facilitated intervention increased provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting. This intervention provided a low-resource approach that has the potential to be scaled and implemented more broadly.

Quitting smoking improves two-year survival after a diagnosis of non-small cell lung cancer

BACKGROUND

Smoking at diagnosis is associated with worse survival in lung cancer but the effects of quitting smoking on survival remain unclear.

METHODS

In a UK multi-centre study (NCT01192256) we followed all 2751 patients with newly diagnosed non-small cell lung cancer (NSCLC) for up to 2 years or until death as part of the observational trial. Patients were offered smoking cessation advice and treatments according to national guidelines and local services. Smoking status was verified by exhaled carbon monoxide levels. Kaplan-Meier survival analysis and Cox Proportional Hazards Modelling examined the effects of quitting smoking on survival at 2 years.

FINDINGS

646 were current smokers at the time of diagnosis. The unadjusted two-year Kaplan-Meier survivor functions for quitters (0.45, 95 %CI 0.37 to 0.53) and continuers (0.32, 0.28 to 0.36) were significantly different (log-rank test p < 0.01). Median survival times were 659 days for quitters and 348 days for continuers. After adjusting for age, sex, stage, performance status, curative intent surgery, radical radiotherapy and comorbidity, the hazard ratio for quitting at diagnosis (0.75, 95 % CI 0.58 to 0.98) indicated a statistically significant reduction in the risk of death across the two-year study period.

INTERPRETATION

Quitting smoking is independently and significantly associated with improved survival regardless of stage in NSCLC. We recommend that smoking cessation advice and treatments should be offered to smokers with lung cancer.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT01192256.

FUNDING

This work was supported by a 2010 Global Research Award for Nicotine Dependence (GRAND), Pfizer.

Modifiable risk factors linked to the development of rheumatoid arthritis: evidence, immunological mechanisms and prevention

Rheumatoid Arthritis (RA) is a common autoimmune disease that targets the synovial joints leading to arthritis. Although the etiology of RA remains largely unknown, it is clear that numerous modifiable risk factors confer increased risk to developing RA. Of these risk factors, cigarette smoking, nutrition, obesity, occupational exposures and periodontal disease all incrementally increase RA risk. However, the precise immunological mechanisms by which these risk factors lead to RA are not well understood. Basic and translational studies have provided key insights into the relationship between inflammation, antibody production and the influence in other key cellular events such as T cell polarization in RA risk. Improving our general understanding of the mechanisms which lead to RA will help identify targets for prevention trials, which are underway in at-risk populations. Herein, we review the modifiable risk factors that are linked to RA development and describe immune mechanisms that may be involved. We highlight the few studies that have sought to understand if modification of these risk factors reduces RA risk. Finally, we speculate that modification of risk factors may be an appealing avenue for prevention for some at-risk individuals, specifically those who prefer lifestyle interventions due to safety and economic reasons.

Association between duration of smoking abstinence before non-small-cell lung cancer diagnosis and survival: a retrospective, pooled analysis of cohort studies

BACKGROUND

The association between duration of smoking abstinence before non-small-cell lung cancer (NSCLC) diagnosis and subsequent survival can influence public health messaging delivered in lung-cancer screening. We aimed to assess whether the duration of smoking abstinence before diagnosis of NSCLC is associated with improved survival.

METHODS

In this retrospective, pooled analysis of cohort studies, we used 26 cohorts participating in Clinical Outcomes Studies of the International Lung Cancer Consortium (COS-ILCCO) at 23 hospitals. 16 (62%) were from North America, six (23%) were from Europe, three (12%) were from Asia, and one (4%) was from South America. Patients enrolled were diagnosed between June 1, 1983, and Dec 31, 2019. Eligible patients had smoking data before NSCLC diagnosis, epidemiological data at diagnosis (obtained largely from patient questionnaires), and clinical information (retrieved from medical records). Kaplan-Meier curves and multivariable Cox models (ie, adjusted hazard ratios [aHRs]) were generated with individual, harmonised patient data from the consortium database. We estimated overall survival for all causes, measured in years from diagnosis date until the date of the last follow-up or death due to any cause and NSCLC-specific survival.

FINDINGS

Of 42 087 patients with NSCLC in the COS-ILCCO database, 21 893 (52·0%) of whom were male and 20 194 (48·0%) of whom were female, we excluded 4474 (10·6%) with missing data. Compared with current smokers (15 036 [40·0%] of 37 613), patients with 1-3 years of smoking abstinence before NSCLC diagnosis (2890 [7·7%]) had an overall survival aHR of 0·92 (95% CI 0·87-0·97), patients with 3-5 years of smoking abstinence (1114 [3·0%]) had an overall survival aHR of 0·90 (0·83-0·97), and patients with more than 5 years of smoking abstinence (10 841 [28·8%]) had an overall survival aHR of 0·90 (0·87-0·93). Improved NSCLC-specific survival was observed in 4301 (44%) of 9727 patients who had quit cigarette smoking and was significant at abstinence durations of more than 5 years (aHR 0·87, 95% CI 0·81-0·93). Results were consistent across age, sex, histology, and disease-stage distributions.

INTERPRETATION

In this large, pooled analysis of cohort studies across Asia, Europe, North America, and South America, overall survival was improved in patients with NSCLC whose duration of smoking abstinence before diagnosis was as short as 1 year. These findings suggest that quitting smoking can improve overall survival, even if NSCLC is diagnosed at a later lung-cancer screening visit. These findings also support the implementation of public health smoking cessation strategies at any time.

FUNDING

The Alan B Brown Chair, The Posluns Family Fund, The Lusi Wong Fund, and the Princess Margaret Cancer Foundation.

Association of smoking with the survival of patients with brain metastasis of lung cancer

Background

Smoking is associated with increased mortality in patients with cancer. However, there are limited data on the impact of smoking on the survival of patients with brain metastases. Therefore, this study aimed to evaluate whether smoking was associated with survival and whether smoking cessation was beneficial to these patients.

Methods

This study used lung cancer with a brain metastasis cohort of the West China Hospital of Sichuan University from 2013 to 2021. Patients were stratified according to smoking history; the distribution, clinical characteristics, and survival data of each group were estimated. Kaplan-Meier analysis and risk analysis were performed for the survival endpoint.

Results

Of the 2,647 patients included in the analysis, the median age was 57.8 years, and 55.4% were men. Among them, 67.1% had no smoking history, 18.9% still smoked, and 14% reported quitting smoking. Compared with never smokers, current smokers [HR, 1.51 (95% CI, 1.35-1.69), p &lt; 0.01] and former smokers [HR, 1.32 (95% CI, 1.16-1.49), p&lt;0.01] had an increased risk of death. However, quitting smoking was not associated with improved survival [HR, 0.90 (95% CI, 0.77-1.04), p = 0.16]. The overall survival increased with the increase of smoking cessation years.

Conclusions

In lung cancer patients with brain metastases, smoking was associated with an increased risk of death, but quitting smoking was not associated with improved survival.

MEETING HIGHLIGHTS: THE THIRD MARIE SKŁODOWSKA-CURIE SYMPOSIUM ON CANCER RESEARCH AND CARE AT ROSWELL PARK COMPREHENSIVE CANCER CENTER, BUFFALO, NY, SEPTEMBER 20-22, 2023

Marie Skłodowska-Curie Symposia on Cancer Research and Care (MSCS-CRC) promote collaborations between cancer researchers and care providers in the United States, Canada and Central and Eastern European Countries (CEEC), to accelerate the development of new cancer therapies, advance early detection and prevention, increase cancer awareness, and improve cancer care and the quality of life of patients and their families. The third edition of MSCS-CRC, held at Roswell Park Comprehensive Cancer Center, Buffalo, NY, in September 2023, brought together 137 participants from 20 academic institutions in the US, Poland, Ukraine, Lithuania, Croatia and Hungary, together with 16 biotech and pharma entities. The key areas of collaborative opportunity identified during the meeting are a) creating of a database of available collaborative projects in the areas of early-phase clinical trials, preclinical development, and identification of early biomarkers; b) promoting awareness of cancer risks and efforts at cancer prevention; c) laboratory and clinical training; and d) sharing experience in cost-effective delivery of cancer care and improving the quality of life of cancer patients and their families. Examples of ongoing international collaborations in the above areas were discussed. Participation of the representatives of the Warsaw-based Medical Research Agency, National Cancer Institute (NCI) of the United States, National Cancer Research Institutes of Poland and Lithuania, New York State Empire State Development, Ministry of Health of Ukraine and Translational Research Cancer Center Consortium of 13 cancer centers from the US and Canada, facilitated the discussion of available governmental and non-governmental funding initiatives in the above areas.

Building staff capability, opportunity, and motivation to provide smoking cessation to people with cancer in Australian cancer treatment centres: development of an implementation intervention framework for the Care to Quit cluster randomised controlled trial

Few rigorous studies provide a clear description of the methodological approach of developing an evidence-based implementation intervention, prior to implementation at scale. This study describes the development, mapping, rating, and review of the implementation strategies for the Care to Quit smoking cessation trial, prior to application in nine cancer services across Australia. Key stakeholders were engaged in the process from conception through to rating, reviewing and refinement of strategies and principles. An initial scoping review identified 21 barriers to provision of evidence-based smoking cessation care to patients with cancer, which were mapped to the Theoretical Domains Framework and Behaviour Change Wheel (BCW) to identify relevant intervention functions. The mapping identified 26 relevant behaviour change techniques, summarised into 11 implementation strategies. The implementation strategies were rated and reviewed against the BCW Affordability, Practicality, Effectiveness and cost-effectiveness, Acceptability, Side-effects/safety, and Equity criteria by key stakeholders during two interactive workshops to facilitate a focus on feasible interventions likely to resonate with clinical staff. The implementation strategies and associated intervention tools were then collated by form and function to provide a practical guide for implementing the intervention. This study illustrates the rigorous use of theories and frameworks to arrive at a practical intervention guide, with potential to inform future replication and scalability of evidence-based implementation across a range of health service settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10742-022-00288-6.

A practical guide for perioperative smoking cessation

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

Smoking cessation by combined medication and counselling: a feasibility study in lung cancer patients

Purpose

Smoking cessation in patients with diagnosed lung cancer has positive effects on cancer therapy and overall prognosis. Despite this, knowledge on smoking cessation in lung cancer patients is sparse.

Methods

This is an observational single centre, 12-week, prospective, single-arm trial at a tertiary lung cancer centre. Responsive patients were enrolled following confirmed lung cancer diagnosis. Smoking cessation intervention included counselling as well as pharmacotherapy. The primary endpoint was the point prevalence abstinence rate at week 12 based on biochemical verification. Secondary endpoints were the abstinence rate at week 26, quality of life and side effects.

Results

80 patients were enrolled. Mean age was 62.6 ± 7.9 years. Most patients (63%) were treated with chemotherapy or radiochemotherapy. 39 patients used nicotine replacement therapy, 35 varenicline whereas six patients did not use pharmacotherapy. During the study period 13 patients died. Data were available in 72 patients after 12 weeks and 57 patients at week 24. Point prevalence abstinence rates were 37.5% (95% CI 26.4–49.7%) at week 12 and 32.8% (95% CI 21.8–45.4%) at week 26, respectively. Quality of life and side effects were not significantly affected by pharmacotherapy.

Conclusion

In conclusion, our results suggest that smoking cessation is feasible in patients with newly diagnosed lung cancer. The observed abstinence rate is comparable to other patient cohorts. Furthermore, pharmacotherapy in addition to cancer therapy was safe and did not show novel side effects in these seriously ill patients. Thus, smoking cessation should be an integral part of lung cancer treatment.

Trial registration The study was conducted in accordance with good clinical practice standards (GCP) and approved by the local ethics committee (16/3/14), the European PAS registry (EUPAS8748) and the German BfArM (NIS-Studien-Nr. 5508). All patients provided written informed consent before study enrollment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02048-1.

Contemporary Concise Review 2021: Pulmonary nodules from detection to intervention

The US Preventive Task Force (USPSTF) has updated screening criteria by expanding age range and reducing smoking history required for eligibility; the International Lung Screen Trial (ILST) data have shown that PLCOM2012 performs better for eligibility than USPSTF criteria. Screening adherence is low (4%-6% of potential eligible candidates in the United States) and depends upon multiple system and patient/candidate-related factors. Smoking cessation in lung cancer improves survival (past prospective trial data, updated meta-analysis data); smoking cessation is an essential component of lung cancer screening. Circulating biomarkers are emerging to optimize screening and early diagnosis. COVID-19 continues to affect lung cancer treatment and screening through delays and disruptions; specific operational challenges need to be met. Over 70% of suspected malignant lesions develop in the periphery of the lungs. Bronchoscopic navigational techniques have been steadily improving to allow greater accuracy with target lesion approximation and therefore diagnostic yield. Fibre-based imaging techniques provide real-time microscopic tumour visualization, with potential diagnostic benefits. With significant advances in peripheral lung cancer localization, bronchoscopically delivered ablative therapies are an emerging field in limited stage primary and oligometastatic disease. In advanced stage lung cancer, small-volume samples acquired through bronchoscopic techniques yield material of sufficient quantity and quality to support clinically relevant biomarker assessment.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Challenges and Adaptations for Providing Smoking Cessation for Patients with Cancer across Canada during the COVID-19 Pandemic

Smoking cessation after a cancer diagnosis can improve health outcomes, but the Coronavirus disease 2019 (COVID-19) pandemic significantly altered healthcare patterns and strained resources, including for smoking cessation support for cancer patients. A Network that included all 13 provinces and territories (jurisdictions) in Canada received funding and coordinated support from a national organization to implement access to smoking cessation support in cancer care between 2016 and 2021, including throughout the COVID-19 pandemic. Descriptive analyses of meetings between the organization and jurisdictions between March of 2020 and August of 2021 demonstrated that all jurisdictions reported disruptions of existing smoking cessation approaches. Common challenges include staff redeployment, inability to deliver support in person, disruptions in travel, and loss of connections with other clinical resources. Common adaptations included budget and workflow adjustments, transition to virtual approaches, partnering with other community resources, and coupling awareness of the harms of smoking and COVID-19. All jurisdictions reported adaptations that maintained or improved access to smoking cessation services. Collectively, data suggest coordinated national efforts to address smoking cessation in cancer care could be crucial to maintaining access during an international healthcare crisis.

Implementation and evaluation of a smoking cessation checklist implemented within Australian cancer services

Introduction

The detrimental impact of smoking tobacco can be mitigated when cancer patients quit smoking. Smoking cessation clinical pathways are inconsistently implemented within Australian cancer services. The aim of this study was to pilot test and evaluate the reach, adoption, and implementation of a smoking cessation checklist within oncology services.

Methods

The checklist was implemented over a 6‐month period in medical and radiation oncology services at two metropolitan and one rural hospital. The RE‐AIM framework guided the evaluation process. Implementation strategies included training, process mapping, and identifying champions. Evaluation measures included a clinical data audit, surveys, and semi‐structured interviews with healthcare professionals (HCPs).

Results

Healthcare professionals (HCPs; N = 63; 41% oncologists, 32% nurses, 27% others) completed 1276 checklists with cancer patients between November 2019 and December 2020. Of the 126 (10%) identified current smokers, 34 (27%) accepted a referral to either Quitline, Nicotine Replacement Therapy, to a general practitioner or dedicated HCP for follow‐up telephone support. There was variation in screening adoption by HCPs across the three hospitals, with 16%, 92% and 89.5% of patients screened respectively. Contextual factors, such as perceived commitment, role identity, and communication processes appeared to influence the outcomes.

Conclusion

A checklist is a simple, effective, and versatile intervention used to standardise smoking cessation practices in medical and radiation oncology services. The checklist supports standardisation of referral practices to smoking cessation services for cancer patients by either oncologist and/or nurses.

When Is It Safe to Operate for Lung Cancer? Selection of Fiscally Responsible Cardiopulmonary Function Tests for Limited Resection (Wedge Resection and Segmentectomy), Standard Lobectomy, Sleeve Lobectomy, and Pneumonectomy

Pulmonary function testing remains the central determinant of candidacy for pulmonary resection and indicator of perioperative risk. For patients with borderline pulmonary function, exercise testing can help determine surgical candidacy either via stair climbing or by obtaining a maximum oxygen consumption. The Thoracic Revised Cardiac Risk Index should be used to select patients for further cardiac testing. Patient comorbidities, medications, functional limitations, and smoking status are also requisite assessments of the preoperative evaluation that influence perioperative outcomes. A minimally invasive approach to pulmonary resection reduces perioperative risk and may be of most benefit to patients with borderline pulmonary function.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The multiple roles and therapeutic potential of clusterin in non-small-cell lung cancer: a narrative review

Worldwide, lung cancer is the most common form of cancer, with an estimated 2.09 million new cases and 1.76 million of death cause in 2018. It is categorized into two subtypes, small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). Although platinum-based chemotherapy or molecular targeted drugs is recommended for advanced stages of NSCLC patients, however, resistance to drug and chemotherapy are hindrances for patients to fully beneficial from these treatments. Clusterin (CLU), also known as apolipoprotein J, is a versatile chaperone molecule which produced by a wide array of tissues and found in most biologic fluids. There are studies reported high expression of CLU confers resistance to chemotherapy and radiotherapy in different lung cancer cell lines. By silencing CLU using Custirsen (OGX-011), a second-generation antisense oligonucleotide (ASO) that inhibits CLU production, not only could sensitized cells to chemo- and radiotherapy, also could decreased their metastatic potential. We will review here the extensive literature linking CLU to NSCLC, update the current state of research on CLU for better understanding of this unique protein and the development of more effective anti- CLU treatment.

A Novel Signature for Predicting Prognosis of Smoking-Related Squamous Cell Carcinoma

Tobacco smoking is an established risk factor for squamous cell carcinoma (SCC). We obtained smoking-related SCC, including cervical SCC (CSCC), esophageal SCC (ESCC), head and neck SCC (HNSC), and lung SCC (LUSC), from The Cancer Genome Atlas (TCGA) database to investigate the association between smoking status (reformed and current smoking) and prognosis. We found that reformed smokers had a better prognosis than current smokers in CSCC (p = 0.003), HNSC (p = 0.019), and LUSC (p < 0.01) cohorts. Then, we selected LUSC cohorts as the training cohort and other SCC cohorts as the test cohorts. Function analysis revealed that homologous recombination (HR) was the most significant pathway involved in smoking-induced LUSC. Moreover, the effect of cross-talk between the smoking status and HR deficiency (HRD) on the prognosis was further evaluated, revealing that quitting smoking with high HRD scores could significantly improve patients’ prognosis (p < 0.01). To improve prognosis prediction and more effectively screen suitable populations for platinum drugs and poly-ADP-ribose polymerase (PARP) inhibitors, we constructed a risk score model using smoking- and HRD-related genes in LUSC. The risk score model had high power for predicting 2-, 3-, and 5-year survival (p < 0.01, AUC = 0.67, 0.66, and 0.66). In addition, the risk scores were an independent risk factor for LUSC (HR = 2.34, 95%CI = 1.70–3.23). The practical nomogram was also built using the risk score, smoking status, and other clinical information with a good c-index (0.72, 95%CI = 0.70–0.74). Finally, we used other TCGA SCC cohorts to confirm the reliability and validity of the risk score model (p < 0.01 and AUC > 0.6 at 2, 3, and 5 years in CSCC and HNSC cohorts). In conclusion, the present study suggested that smoking cessation should be a part of smoking-related SCC treatment, and also provided a risk score model to predict prognosis and improve the effectiveness of screening the platinum/PARP population.

Mixed-methods economic evaluation of the implementation of tobacco treatment programs in National Cancer Institute-designated cancer centers

Background

The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications.

Methods

We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs.

Results

Median total monthly operating costs across funded centers were $11,045 (range: $5129–$20,751). The largest median operating cost category was personnel ($10,307; range: $4122–$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17–$573), materials ($6–$435), training ($96–$516), technology ($171–$2759), and equipment ($10–$620). Median cost-per-participant was $466 (range: $70–$2093) and cost-per-quit was $2688 (range: $330–$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications.

Conclusions

Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Age at first birth and lung cancer: a two-sample Mendelian randomization study

Background

Growing evidence suggests that female reproductive factors, like age at first birth (AFB), may play a potential role in the progression of lung cancer (LC). However, previous studies are susceptible to confounding factors, inadequate attention to variation by histology or reverse causality. Few studies have comprehensively evaluated their association and the causal effect remains unclear.

Methods

We aimed to determine whether AFB is causally correlated with the risk of LC, by means of utilizing aggregated data from the large genome-wide association studies conducted on AFB (251,151 individuals) and data of LC from International Lung and Cancer Consortium (ILCCO, 11,348 cases and 15,861 controls). We used 10 AFB-related single nucleotide polymorphisms as instrument variables and applied several two-sample Mendelian randomization (MR) methods. Secondary results according to different histological subtypes of lung cancer were also implemented.

Results

Conventional inverse-variance weighted method indicated that genetic predisposition towards number unit (1 year) increase of AFB was associated with a 18% lower risk of LC [odds ratio (OR) =0.82, 95% confidence interval (CI): 0.69–0.97; P=0.029]. When results were examined by histotypes, an inverse association was observed between genetically predisposed number unit (1 year) increase of AFB and lung adenocarcinoma (OR =0.75, 95% CI: 0.59–0.97, P=0.017) but not with squamous cell lung cancer (OR =0.77, 95% CI: 0.57–1.05, P=0.103). The results demonstrated no association between number unit decrease of AFB and LC. Pleiotropy was not presented through sensitivity analyses including MR pleiotropy residual sum and outlier test (P=0.412). Genetic predisposition towards older AFB was additionally associated with longer years of schooling (OR =1.12, 95% CI: 1.08–1.16, P<0.001), lower body mass index (OR =0.93, 95% CI: 0.88–0.98, P=0.004) and less alcohol consumption (OR =0.99, 95% CI: 0.99–1.00, P=0.004).

Conclusions

Our study suggested that older AFB was a causal protective factor in the progression of LC. Further studies elucidating the potential mechanisms are needed.

Efficacy of an inpatient smoking cessation program at a single regional cancer center: A prospective observational study

ABSTRACT

Smoking is the leading cause of preventable death and a risk factor for cancer, but smoking cessation is difficult even in patients who need hospitalization. This study aimed to investigate the usefulness of an inpatient smoking cessation consultation program and to analyze the clinical factors associated with abstinence. In this observational study, patients received regular counseling for 6 months, and abstinence was objectively assessed via urine and exhaled carbon monoxide testing. Cessation rates were assessed at 4 weeks and 6 months, and clinical characteristics associated with cessation success were investigated. Of the 571 patients referred to participate in the program, 170 (29.8%) were enrolled, and only 2 (1.2%) used smoking cessation drugs in addition to counseling. The smoking cessation rate was 77.6% after 4 weeks and 59.1% after 6 months. The cessation rates were significantly higher in patients with cancer than in those without cancer at both timepoints (63.8% vs 21.9%, P < .001, 53.6% vs 12.5%, P < .001), and they were also higher in the first admission group than in the re-admission group (87.4% vs 74.7%, P = .033, 88.5% vs 76.1%, P = .037). In patients with lung cancer, progression-free survival and overall survival tended to be better in those enrolled in the program (P = .158, P = .183). In conclusion, the inpatient smoking cessation program was associated with a high abstinence rate. Most patients maintained cessation without medication, suggesting that initial admission, along with a cancer diagnosis, can provide enough motivation to abstain from smoking. In addition, the smoking cessation effort showed potential to improve survival during lung cancer treatment.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Tobacco Use and Treatment among Cancer Survivors

Tobacco use is causally associated with the risk of developing multiple health conditions, including over a dozen types of cancer, and is responsible for 30% of cancer deaths in the U [...].

The cost of failed first-line cancer treatment related to continued smoking in Canada

Background

Smoking by cancer patients and survivors causes adverse cancer treatment outcomes, but little information is available about how smoking can affect cancer treatment costs.

Methods

We developed a model to estimate attributable cancer treatment failure because of continued smoking after a cancer diagnosis (afs). Canadian health system data were used to determine the additional treatment cost for afs for the most common cancers in Canada.

Results

Of 206,000 patients diagnosed with cancer annually, an estimated 4789 experienced afs. The annual incremental cost associated with treating patients experiencing afs was estimated at between $198 million and $295 million (2017 Canadian dollars), reflecting an added incremental cost of $4,810-$7,162 per patient who continued to smoke. Analyses according to disease site demonstrated higher incremental costs where the smoking prevalence and the cost of individual second-line cancer treatment were highest. Of breast, prostate, colorectal, and lung cancers, lung cancer was associated with the highest incremental cost for treatment after afs.

Conclusions

The costs associated with afs in Canada after a cancer diagnosis are considerable. Populations in which the smoking prevalence and treatment costs are high are expected to benefit the most from efforts aimed at increasing smoking cessation capacity for patients newly diagnosed with cancer.

Practical implications to contemplate when considering radical therapy for stage III non-small-cell lung cancer

The type of patients with stage III non-small-cell lung cancer (NSCLC) selected for concurrent chemoradiotherapy (cCRT) varies between and within countries, with higher-volume centres treating patients with more co-morbidities and higher-stage disease. However, in spite of these disease characteristics, these patients have improved overall survival, suggesting that there are additional approaches that should be optimised and potentially standardised. This paper aims to review the current knowledge and best practices surrounding treatment for patients eligible for cCRT. Initially, this includes timely acquisition of the full diagnostic workup for the multidisciplinary team to comprehensively assess a patient for treatment, as well as imaging scans, patient history, lung function and genetic tests. Such information can provide prognostic information on how a patient will tolerate their cCRT regimen, and to perhaps limit the use of additional supportive care, such as steroids, which could impact on further treatments, such as immunotherapy. Furthermore, knowledge of the safety profile of individual double-platinum chemotherapy regimens and the technological advances in radiotherapy could aid in optimising patients for cCRT treatment, improving its efficacy whilst minimising its toxicities. Finally, providing patients with preparatory and ongoing support with input from dieticians, palliative care professionals, respiratory and care-of-the-elderly physicians during treatment may also help in more effective treatment delivery, allowing patients to achieve the maximum potential from their treatments.

Quality of smoking cessation advice in guidelines of tobacco-related diseases: An updated systematic review

Tobacco smoking is a major risk factor for a wide range of diseases, and smoking cessation significantly reduces these risks. Clinical guidelines for diseases associated with smoking should therefore include guidance on smoking cessation. This review updated evidence on the proportion of clinical guidelines that do so. We conducted a systematic review investigating clinical guidelines and recommendations developed by UK national or European transnational medical specialty associations and societies between January 2014 and October 2019 on 16 diseases to be at least twice as common among smokers than non-smokers. Outcomes of interest were the reporting of smoking as a risk factor, and the inclusion either of smoking cessation advice or referral to other cessation guidance. We compared our findings with an earlier review of guidelines published between 2000 and 2013. We identified 159 clinical guidelines/recommendations. Over half (51%) made no mention of smoking, while 43% reported smoking as a risk factor for the development of the disease, 31% recommended smoking cessation and 19% provided detailed information on how to deliver smoking cessation support. These proportions were similar to those in our earlier review. Smoking cessation continues to be neglected in clinical management guidance for diseases caused by smoking.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Smoking cessation and survival among people diagnosed with non-metastatic cancer

Background

We aimed to estimate the effects of smoking cessation on survival among people diagnosed with cancer.

Methods

We used data from a Comprehensive Community Cancer Program that is part of a large urban safety-net hospital system. Eligible patients were diagnosed with primary invasive solid tumors between 2013 and 2015, and were current smokers at time of diagnosis. Our exposure of interest was initiation of smoking cessation within 6 months of cancer diagnosis. We estimated inverse probability weighted restricted mean survival time (RMST) differences and risk ratio (RR) for all cause 3-year mortality.

Results

Our study population comprised 369 patients, of whom 42% were aged < 55 years, 59% were male, 44% were racial/ethnic minorities, and 59% were uninsured. The 3-year RMST was 1.8 (95% CL: − 1.5, 5.1) months longer for individuals who initiated smoking cessation within 6 months of cancer diagnosis. The point estimate for risk of 3-year mortality was lower for initiation of smoking cessation within 6 months of diagnosis compared with no initiation within 6 months (RR = 0.72, 95% CL: 0.37, 1.4).

Conclusions

Our point estimates suggest longer 3-year survival, but the results are compatible with 1.5 month shorter or 5.1 longer 3-year overall survival after smoking cessation within 6 months of cancer diagnosis. Future studies with larger sample sizes that test the comparative effectiveness of different smoking cessation strategies are needed for more detailed evidence to inform decision-making about the effect of smoking cessation on survival among cancer patients.

Implications for Cancer survivors

The benefits of smoking cessation after cancer diagnosis may include longer survival, but the magnitude of benefit is unclear.

The effectiveness of distance‐based interventions for smoking cessation and alcohol moderation among cancer survivors: A meta‐analysis

OBJECTIVE

The objective of this study is to evaluate current evidence for the effectiveness of distance-based interventions to support smoking cessation (SC) or alcohol moderation (AM) among cancer survivors. Secondary, differences in effectiveness are explored regarding multibehaviour interventions versus single-behaviour interventions targeting SC or AM only.

METHODS

A systematic search of PubMed, PsycINFO, Web of Science, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials was conducted. Intervention studies with and without control groups and randomized controlled trials were included. Random effects meta-analyses were conducted for the main outcomes: SC and AM rates at the follow-up closest to 6 months. Using subgroup analyses and meta-regression, effectiveness of single-behaviour versus multibehaviour interventions was evaluated.

RESULTS

A total of 17 studies with 3796 participants; nine studies on SC only, eight studies on multibehaviour interventions including an SC or AM module, and no studies on AM only were included. All studies had at least some concerns regarding bias. Distance-based SC interventions led to higher cessation rates than control conditions (10 studies, odds ratio [OR] = 1.56; 95% CI, 1.13-2.15, P = .007). Single-behaviour SC interventions reduced smoking rates compared with baseline (risk difference [RD] = 0.29; 95% CI, 0.19-0.39, P < .0001), but multibehaviour interventions did not (RD = 0.13; 95% CI, -0.05 to 0.31, P = 0.15). There was insufficient evidence that distance-based multibehaviour interventions reduced alcohol use compared with controls (three studies, standardized mean difference [SMD] = 0.12; 95% CI, -0.08 to 0.31, P = .24).

CONCLUSIONS

Distance-based SC interventions are effective in supporting SC among cancer survivors. Single-behaviour SC interventions appear more effective than multibehaviour interventions. No evidence was found for the effectiveness of distance-based AM interventions for cancer survivors.

Evaluation of a Dedicated Tobacco Cessation Support Service for Thoracic Cancer Center Patients

CONTEXT

Cancer patients' continued tobacco use results in poorer therapeutic outcomes including decreased quality of life and survival.

OBJECTIVE

To assess reach and impact of a free, opt-out, telephone-based tobacco cessation program for thoracic cancer center patients.

DESIGN

Observational study.

SETTING

Comprehensive Cancer Center in Western New York.

PARTICIPANTS

Current or recent (within past 30 days) tobacco-using thoracic cancer center patients referred to a tobacco cessation support service between October 2010 and October 2012 at a Comprehensive Cancer Center (n = 942/1313 referrals were eligible for cessation support).

INTERVENTION

A free, opt-out, telephone-based cessation service that was implemented as standard of care. Cessation specialists had patient-guided conversations that assessed readiness to quit; methods used in the past provided cessation strategies and worked to set up a quit date. There was an average of 35.9 days between referral and first contact.

MAIN OUTCOME MEASURES

Program reach (referral and participation rates) and impact (as self-reported cessation outcomes measured twice after referral).

RESULTS

Of 942 patients, 730 (77.5%) referred to and called by a tobacco cessation service participated in at least 1 cessation support call, of which 440 of 730 (60.3%) were called for follow-up and 89.5% (394/440) participated. In total, 20.2% (69/342) of current smokers at referral reported at least 7-day abstinence at follow-up. Among current smokers at referral and first contact, being married (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.01-4.18) and having a lower Eastern Cooperative Oncology Group (ECOG) performance score (OR = 4.05; 95% CI, 1.58-10.39) were associated with quitting at follow-up, after controlling for demographic, clinical, and health behavior characteristics.

CONCLUSIONS

Our results demonstrate that 78% of thoracic cancer center patients, if contacted, participated at least once in this cessation support service; for current smokers at referral and first contact, being married and having a lower ECOG performance score were associated with self-reported quitting at follow-up. Other organizations may find our results useful while implementing a systematic way to identify tobacco-using patients as part of routine care and to improve available cessation support services.

Feasibility and Acceptability of Mindfulness-Based Group Visits for Smoking Cessation in Low-Socioeconomic Status and Minority Smokers with Cancer

Objective: Smoking cessation studies tailored for low-income and racial/ethnic minority cancer patients are limited. African American and low-socioeconomic status (SES) smokers have higher cancer mortality rates and are less likely to use evidence-based smoking cessation treatments compared with white and higher SES counterparts. Mindfulness training is a promising approach to address racial and SES disparities in smoking cessation. The authors assessed the feasibility and acceptability of a mindfulness-based smoking cessation (MBSC) medical group visit for low-income and racially diverse smokers with cancer. Design and intervention: The authors adapted the integrative medical group visit model used for chronic pain and included the You Can Quit smoking cessation curriculum used at the study site, Tobacco Treatment Center. The program was conducted in eight weekly 2-h visits. The authors then tested the feasibility and acceptability of this intervention for actively smoking cancer patients and cancer survivors in two pilot groups (N = 18) using a pre-post design. Setting/Location: This study took place at Boston Medical Center, a large urban safety net academic teaching hospital. Outcome measures: The authors used a medical group visit intake form to collect data on weekly cigarette intake and home practice. They also gathered additional qualitative data from focus groups and in-depth interviews. Results: Over 50% of participants (n = 10) self-identified as black and 56% reported an annual income of $20,000 or less. Over two-thirds of the participants attended four or more of the eight group visits. There was a significant decrease in weekly cigarette intake from 75.1 cigarettes at baseline to 44.3 at 3 months (p = 0.039). None of the participants quit smoking. Participants were satisfied with the program and reported positive lifestyle changes. Conclusion: MBSC group visits are feasible and acceptable among racially diverse and low-SES smokers with cancer and should be further studied in a larger cohort.

Impact of smoking on health system costs among cancer patients in a retrospective cohort study in Ontario, Canada

OBJECTIVE

Smoking is the main modifiable cancer risk factor. The objective of this study was to examine the impact of smoking on health system costs among newly diagnosed adult patients with cancer. Specifically, costs of patients with cancer who were current smokers were compared with those of non-smokers from a publicly funded health system perspective.

METHODS

This population-based cohort study of patients with cancer used administrative databases to identify smokers and non-smokers (1 April 2014-31 March 2016) and their healthcare costs in the 12-24 months following a cancer diagnosis. The health services included were hospitalisations, emergency room visits, drugs, home care services and physician services (from the time of diagnosis onwards). The difference in cost (ie, incremental cost) between patients with cancer who were smokers and those who were non-smokers was estimated using a generalised linear model (with log link and gamma distribution), and adjusted for age, sex, neighbourhood income, rurality, cancer site, cancer stage, geographical region and comorbidities.

RESULTS

This study identified 3606 smokers and 14 911 non-smokers. Smokers were significantly younger (61 vs 65 years), more likely to be male (53%), lived in poorer neighbourhoods, had more advanced cancer stage,and were more likely to die within 1 year of diagnosis, compared with non-smokers. The regression model revealed that, on average, smokers had significantly higher monthly healthcare costs ($5091) than non-smokers ($4847), p<0.05.

CONCLUSIONS

Smoking status has a significant impact on healthcare costs among patients with cancer. On average, smokers incurred higher healthcare costs than non-smokers. These findings provide a further rationale for efforts to introduce evidence-based smoking cessation programmes as a standard of care for patients with cancer as they have the potential not only to improve patients' outcomes but also to reduce the economic burden of smoking on the healthcare system.

Mitigating the adverse health effects and costs associated with smoking after a cancer diagnosis

Smoking after a cancer diagnosis causes adverse outcomes and is associated with substantial additional treatment cost. Mitigation of the adverse effects of smoking require active commitment from health systems, providers, and patients. Three areas of mitigation are discussed: (I) smoking cessation after a cancer diagnosis to improve cancer treatment outcomes; (II) identifying optimal cancer treatment strategies for patients who smoke at the time of diagnosis; and (III) how health systems can prioritize the effect modification caused by smoking. As innovation continues for healthcare delivery, priority should be placed on interventions that reduce the effect modification and associated costs caused by continued smoking after a cancer diagnosis.

Integration of smoking cessation and lung cancer screening

The National Lung Screening Trial demonstrated a decrease in both lung cancer mortality and overall mortality in enrollees aged 55-74 with a 30 pack-year smoking history using low-dose computed tomography (LDCT). Lung cancer screening in high-risk groups is supported by the United States Preventive Services Task Force, the National Comprehensive Cancer Network, and multiple other organizations. Inclusion for any lung screening program requires a history of smoking, and many undergoing screening are currently smoking. Screened patients are not only at risk for developing lung cancer, but also carry the risk of developing a host of other smoking related diseases, and cessation at any point is beneficial. Counseling and pharmacotherapy are evidence-based strategies which are well known to help people quit smoking. However, as lung cancer screening is an emerging and evolving field, the integration of cessation resources in screening programs is not uniformly done, and when it is done, there is no standardized approach. The goals of this review are to discuss the rationale for integrating smoking cessation resources in lung cancer screening, review what types of resources may be effective, and discuss different strategies of how integration can be done. Ultimately, the overarching goal of any lung cancer screening program is not merely to find more nodules, or diagnose more cases of cancer, but to help screened patients live longer, better lives. Smoking cessation broadens the impact of any lung cancer screening program well beyond the endpoints of cancer diagnosis and cancer mortality to reduce risk from many other diseases, and can positively impact many more patients than the small percentage that have cancer.

Pulmonary delivery of transferrin receptors targeting peptide surface-functionalized liposomes augments the chemotherapeutic effect of quercetin in lung cancer therapy

Purpose: Lung cancer has a high incidence rate worldwide with a 5-year survival rate of 18%, and is the leading cause of cancer-related deaths. The aim of this study is to augment therapeutic efficacy of quercetin (QR) for lung cancer therapy by targeting transferrin receptors, which are overexpressed and confined to tumor cells. Methods: In this study, T7 surface-functionalized liposomes loaded with QR (T7-QR-lip) having different T7 peptide densities (0.5%, 1% and 2%) were prepared by the film hydration method. T7 surface-functionalized liposomes were characterized and evaluated in terms of in vitro cytotoxicity and cellular uptake, 3D tumor spheroid penetration and inhibition capabilities, in vivo biodistribution and therapeutic efficacy in mice with orthotopic lung-tumor implantation by fluorescent and bioluminescent imaging via pulmonary administration. Results: In vitro, 2% T7-QR-lip exhibited significantly augmented cytotoxicity (~3-fold), higher apoptosis induction and S-phase cell-cycle arrest. A prominent peak right-shift and enhanced mean fluorescence intensity was observed in A549 cells treated with T7 Coumarin-6 liposomes (T7-Cou6-lip), confirming the target specificity of T7 targeted liposomes; while, after treatment with T7-QR-lip and non-targeted QR-lip, no significant difference was observed in cellular uptake and in vitro cytotoxicity studies in MRC-5 (normal lung fibroblast) cells. T7-Cou6-lip showed higher fluorescence intensity in A549 cells and a significantly deeper penetration depth of 120 µm in the core of the tumor spheroids and T7-QR-lip produced significantly higher tumor-spheroid growth inhibition. The in vivo biodistribution study via pulmonary delivery of T7 1,1'-dioctadecyltetramethyl-indotricarbocyanine iodide liposomes demonstrated liposome accumulation in the lungs and sustained-release behavior up to 96 h. Further, T7-QR-lip significantly enhanced the anticancer activity of QR and lifespan of mice (p<0.01, compared with saline) in orthotopic lung tumor-bearing mice via pulmonary administration. Conclusion: T7 surface-functionalized liposomes provide a potential drug delivery system for a range of anticancer drugs to enhance their therapeutic efficacy by localized (pulmonary) administration and targeted delivery.

Attributable Failure of First-line Cancer Treatment and Incremental Costs Associated With Smoking by Patients With Cancer

IMPORTANCE

Previous studies have shown that continued smoking among patients with cancer can increase overall and cancer-specific mortality, risk for second primary cancer, and risk for toxic effects of cancer treatment. To our knowledge, there have been no efforts to estimate additional costs for cancer treatment attributed to smoking.

OBJECTIVE

To model attributable incremental costs of subsequent cancer treatment associated with continued smoking by patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

For this economic evaluation, a model was developed in 2018 using data from a 2014 US Surgeon General's report that considered expected failure rates of first-line cancer treatment in nonsmoking patients, smoking prevalence, odds ratio of first-line cancer treatment failure attributed to smoking compared with nonsmoking, and cost of cancer treatment after failure of first-line cancer treatment.

MAIN OUTCOMES AND MEASURES

Attributable failures of first-line cancer treatment and incremental cost for subsequent treatment associated with continued smoking among patients with cancer.

RESULTS

Attributable treatment failures were higher under conditions in which high first-line cure rates were expected in nonsmoking patients compared with conditions in which low cure rates were expected. Peak attributable failures occurred under the conditions in which expected cure rates among nonsmoking patients ranged from 50% to 65%. Under the conditions of a 30% expected treatment failure rate among nonsmoking patients, 20% smoking prevalence, 60% increased risk of failure of first-line cancer treatment, and $100 000 mean added cost of treating a first-line cancer treatment failure, the additional incremental cost per 1000 total patients was estimated to be $2.1 million, reflecting an additional cost of $10 678 per smoking patient. Extrapolation of cost to 1.6 million patients with cancer diagnosed annually reflects a potential $3.4 billion in incremental cost.

CONCLUSIONS AND RELEVANCE

The findings suggest that continued smoking among patients with cancer and the increase in attributable first-line cancer treatment failure is associated with significant incremental costs for subsequent cancer treatments. Additional work appears to be needed to identify optimal methods to mitigate these incremental costs.

Docosapentaenoic acid and lung cancer risk: A Mendelian randomization study

BACKGROUND

Observational studies have shown that excessive dietary fat may be associated with lung carcinogenesis. However, findings from previous studies are inconsistent and it remains unclear whether docosapentaenoic acid (DPA), a kind of polyunsaturated fatty acid, is linked to the risk of lung cancer. The aim of this study is to investigate the causal effect of DPA on lung cancer with Mendelian randomization (MR) method.

METHODS

With a two-sample MR approach, we analyzed the summary data from the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE, 8866 individuals of European ancestry) Consortium and International Lung Cancer Consortium (ILCCO, 11 348 lung cancer cases and 15 861 controls; European ancestry) to assess the possible causal relationship of DPA on the risk of lung cancer.

RESULTS

Our results indicated that genetically predicted higher DPA level has a positive association with lung cancer, where 1% higher DPA was associated with a 2.01-fold risk of lung cancer (odds ratio [OR]: 2.01, 95% CI = 1.34-3.01; P = 7.40 × 10^-4 ). Additionally, lung cancer was not a causal factor for DPA. The results of MR-Egger regression analysis showed that there was no evidence for the presence of directional horizontal pleiotropy.

CONCLUSIONS

Genetically elevated DPA is positively associated with risk of lung cancer, and more work is needed to investigate the potential mechanisms.

Smoking cessation attitudes and practices among cancer survivors - United States, 2015

PURPOSE

The prevalence of smoking among cancer survivors is similar to the general population. However, there is little evidence on the prevalence of specific smoking cessation behaviors among adult cancer survivors.

METHODS

The 2015 National Health Interview Survey (NHIS) data were analyzed to examine the prevalence of smoking cessation behaviors and use of treatments among cancer survivors. Weighted self-reported prevalence estimates and 95% confidence intervals were calculated using a sample of 2527 cancer survivors.

RESULTS

Among this sample of US cancer survivors, 12% were current smokers, 37% were former smokers, and 51% were never smokers. Compared with former and never smokers, current smokers were younger (< 65 years), less educated, and less likely to report being insured or Medicaid health insurance (p < 0.01). More males were former smokers than current or never smokers. Current smokers reported wanting to quit (57%), a past year quit attempt (49%), or a health professional advised them to quit (66%). Current smokers reported the use of smoking cessation counseling (8%) or medication (38%).

CONCLUSIONS

Even after a cancer diagnosis, about one in eight cancer survivors continued to smoke. All could have received advice to quit smoking by a health professional, but a third did not.

IMPLICATIONS FOR CANCER SURVIVORS

Health professionals could consistently advise cancer survivors about the increased risks associated with continued smoking, provide them with cessation counseling and medications, refer them to other free cessation resources, and inform them of cessation treatments covered by their health insurance.

Longitudinal study to assess impact of smoking at diagnosis and quitting on 1-year survival for people with non-small cell lung cancer

OBJECTIVES

To update the prevalence of smoking in people as they were diagnosed with non-small cell lung cancer (NSCLC) and to see whether smoking status at baseline and quitting are independently associated with 1-year survival.

DESIGN

A real-world cohort study following patients from diagnosis for up to 1 year or until death.

SETTING

UK multi-centre study (28 sites) based in secondary and primary care.

PARTICIPANTS

1124 patients with newly diagnosed NSCLC between 2010-2016.

MAIN OUTCOME MEASURES

Smoking status was validated at diagnosis and at every routine and emergency hospital visit. Cancer treatments were offered according to local multi-disciplinary team decisions following UK guidelines and smoking cessation treatments offered according to local practice /availability. Survival analysis and Cox Proportional Hazards Modelling examined the associations of a) smoking at baseline and b) quitting smoking, on survival at 1 year.

RESULTS

77% of never smokers, 60% of ex-smokers and 57% of current smokers, were alive at 1 year (p = 0.01). After adjusting for age, stage, EGOG, surgery and gender, ex smokers (adjusted HR 1.96, 95% CI 1.16-2.31) and current smokers (aHR 2.04, 1.19-3.48) were both more likely to die within one year. 23% of smokers with NSCLC quit within 3 months of diagnosis. At 1 year, 69% of those who quit were alive versus 53% of those who continued to smoke (p < 0.01). After adjusting the risk of dying was lower (aHR 0.75), in those who quit smoking, although this was not statistically significant (p = 0.23).

CONCLUSIONS

This is the largest prospective study that validates smoking in NSCLC; it shows a third of people are smoking at the time of diagnosis. Smokers have lower 12-month survival than never and ex -smokers. Quitting smoking was associated with 25% reduction in mortality which may be clinically important although not statistically significant, after adjusting for other factors.