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

Tobacco Cessation Following Laryngeal Cancer Diagnosis Predicts Response to Treatment and Laryngectomy-Free Survival

OBJECTIVE

To determine the effect of tobacco cessation following laryngeal cancer diagnosis on response to first-line therapy, laryngectomy-free survival, and overall survival in patients who were current smokers at the time of diagnosis.

STUDY DESIGN

Retrospective, case-control study.

SETTING

OU Stephenson Cancer Center, National Cancer Institute-Designated Cancer Center.

METHODS

We included 140 patients diagnosed with laryngeal squamous cell carcinoma, who were current smokers at the time of diagnosis, and were treated with first-line definitive radiation or chemo/radiation with the intent to cure. The association between patient characteristics and treatment response was assessed using the χ2 test and logistic regression analysis. Survival outcomes were analyzed using Kaplan-Meier methods and Cox proportional-hazards models.

RESULTS

Of the 140 current smokers, 61 patients (45%) quit smoking prior to treatment initiation. In adjusted logistic regression analysis, quitters had 3.7 times higher odds of achieving a complete response to first-line therapy than active smokers (odds ratio: 3.694 [1.575-8.661]; P = .003). In the adjusted Cox proportional-hazards model, quitters were 54% less likely to require salvage laryngectomy within 7 years of diagnosis than active smokers (hazard ratio: 0.456 [0.246-0.848]; P = .013). Quitters had a statistically significant increase in 7-year overall survival compared to active smokers (P = .02).

CONCLUSION

This is the first study to show that in newly diagnosed laryngeal cancer patients who are current smokers at the time of diagnosis, tobacco cessation significantly increases therapy response, laryngectomy-free survival, and overall survival. These data stress the importance of systematically incorporating tobacco cessation programs into laryngeal cancer treatment plans.

Physical Activity, Alcohol, and Cigarette Use in Urological Cancer Patients over Time since Diagnosis

Urological cancers represent a substantial global public health concern, exerting far-reaching effects on both individuals and their families. There is an urgent need to comprehensively understand the transformations in patients' lifestyles and behaviors, given their critical role in the treatment process and overall well-being. This study, involving 128 urological cancer patients, aims to investigate changes in physical activity levels, problematic drinking behaviors assessed through the Alcohol Use Disorders Identification Test (AUDIT), and smoking habits assessed using the Fagerström Test for Nicotine Dependence (FTND) over four distinct time intervals over the subsequent three years from the time of diagnosis and among individuals diagnosed more than three years ago. The results reveal a significant decrease in physical activity levels between study intervals (p < 0.0001), declining from 69% to 45% between the first and second post-diagnosis assessments. Furthermore, the highest levels of problematic substance use, indicated by mean scores, were noted in the first year following diagnosis (AUDIT: 4.20, p = 0.01; FTND: 4.83, p = 0.08). Given the significant impact of physical activity on the prospects of recovery, it is imperative to delve more deeply into the factors contributing to this decline and devise targeted interventions for its improvement. In the context of substance use, it is essential to ascertain whether the initially high levels are a result of coping with the cancer diagnosis or represent a turning point at which patients modify their behaviors and cease their addiction. A more thorough understanding of this phenomenon would enhance the effectiveness of precisely focused interventions.

Examination of Predictors of Pain at 12 Months Postdiagnosis in Head and Neck Cancer Survivors

OBJECTIVE

Pain following the completion of treatment is important but has received less attention in the head and neck cancer (HNC) literature. The present study sought to examine the prevalence and predictors of pain measured 12 months postdiagnosis and its impact on HNC-specific health-related quality of life (HRQOL) in 1038 HNC survivors.

STUDY DESIGN

Prospective observational study.

SETTING

Single-institution tertiary care center.

METHODS

Pain was measured using a single item ranging from 0 to 10 with 0 representing no pain and 10 representing the worst pain possible. Self-reported depressive symptomatology was measured using the Beck Depression Inventory and self-reported problem alcohol use was measured by the Short Michigan Alcoholism Screening Test. HNC-specific HRQOL was measured using the Head and Neck Cancer Inventory (HNCI).

RESULTS

Hierarchical multivariable linear regression analyses indicated that in addition to pain at 3 months postdiagnosis (β = .145, t = 3.18, sr2  = .019, p = .002), both depressive symptomatology (β = .110, t = 2.49, sr2  = .011, p = .015) and problem alcohol use (β = .092, t = 2.07, sr2  = .008, p = .039) were significant predictors of pain at 12 months postdiagnosis. Subgroup analyses suggest that across all 4 HNCI domains, those in the moderate and severe pain groups at 12 months postdiagnosis failed to reach 70 which is indicative of high functioning.

CONCLUSION

Pain in patients with HNC is a considerable issue at 12 months postdiagnosis, deserving further attention. Behavioral factors such as depression and problem alcohol use may be associated with pain and require systematic screening over time to identify and treat issues that impact optimal long-term recovery from HNC, including disease-specific HRQOL.

Unmet Needs and Receipt of Supportive Care Services in Head and Neck Cancer Patients Prior to Oncologic Treatment: A Prospective, Cross-Sectional Pilot Study

OBJECTIVE

To characterize the supportive care (SC) needs and receipt of SC services among head and neck cancer (HNC) patients prior to oncologic treatment and to explore the influence of social determinants of health on these outcomes.

MATERIALS AND METHODS

Newly diagnosed HNC patients were surveyed via telephone prior to oncologic treatment between 10/2019 and 1/2021 using a prospective, cross-sectional, bi-institutional, pilot study design. The primary study outcome was unmet SC needs (Supportive Care Needs Survey-Short Form34 [SCNS-SF34]). Hospital type (university- vs county safety-net) was explored as an exposure. Descriptive statistics were performed using STATA16 (College Station, TX).

RESULTS

Among 158 potentially eligible patients, 129 were successfully contacted, 78 met the study criteria, and 50 completed the survey. The mean age was 61, 58% exhibited clinical stage III-IV disease, and 68% and 32% were treated at the university and county safety-net hospital, respectively. Patients were surveyed a median of 20 days after their first oncology visit and 17 days prior to initiation of oncology treatment. They had a median of 24 total needs (11 were met and 13 were unmet) and preferred to see a median of 4 SC services but received care from none. County safety-net patients had comparatively more unmet needs than university patients (14.5 vs 11.5, P = .04).

CONCLUSION

Pretreatment HNC patients at a bi-institutional academic medical center report a high number of unmet SC needs with corollary poor receipt of available SC services. Novel interventions to address this significant gap in care are needed.

Lifestyle Factors in Patients with Bladder Cancer: A Contemporary Picture of Tobacco Smoking, Electronic Cigarette Use, Body Mass Index, and Levels of Physical Activity

BACKGROUND

Little is known about contemporary lifestyle choices in patients with bladder cancer (BC). These choices include carcinogenic risk factors and could affect fitness to receive treatments.

OBJECTIVE

To evaluate the contemporary lifestyle choices in BC patients.

DESIGN, SETTING, AND PARTICIPANTS

Self-reported surveys from participants diagnosed with BC in the previous 10 yr captured smoking patterns, e-cigarette use, physical activity using the GODIN Leisure-Time Exercise Questionnaire, long-term conditions (LTCs), relationship status, sociodemographics, and body mass index (BMI; height and weight).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Findings were compared with the general population and men with prostate cancer.

RESULTS AND LIMITATIONS

Completed surveys were received from 2092 participants. Most respondents were ex-smokers (61% vs 10% current vs 29% never). The use of e-cigarettes was uncommon (9%) and at lower rates than the age-equivalent general population. Passive smoke exposure was frequent (48%). Most participants (68%) were "insufficiently active" using the GODIN criteria and less physically active than the age-equivalent general population. Most respondents (44%) were classified as overweight (BMI 25-29.99) or obese (22%, BMI >30). Lifestyle factors varied with age, sex, socioeconomic deprivation, and LTCs. Younger participants were less likely to smoke (p < 0.001), more likely to have used e-cigarettes (p < 0.001), but more likely to have had passive smoke exposure (p = 0.008). Those from less affluent areas were more likely to smoke (p < 0.001), have used e-cigarettes (p < 0.001), and have had passive smoke exposure (p = 0.02). Females were less likely to be smokers (p < 0.001) but more likely to have been exposed to passive smoke (p < 0.001).

CONCLUSIONS

Persons affected by BC often have smoking exposures and high BMI, and are insufficiently active. Rates of e-cigarette use were lower than in the general population. Efforts to improve quality of life in this cohort should include wider advocation of smoking cessation, perhaps including the use of e-cigarettes, and programmes to increase exercise and reduce BMI.

PATIENT SUMMARY

We looked at the lifestyle choices, such as smoking, e-cigarette use, physical activity levels, and obesity, of patients following a bladder cancer diagnosis. We conclude that this population would benefit from healthy lifestyle interventions.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sick and depressed? The causal impact of a diabetes diagnosis on depression

BACKGROUND

There is sparse evidence on the impact of health information on mental health as well as on the mechanisms governing this relationship. We estimate the causal impact of health information on mental health via the effect of a diabetes diagnosis on depression.

METHODS

We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value of a biomarker used to diagnose type-2 diabetes (glycated haemoglobin, HbA1c) and information on psycometrically validated measures of diagnosed clinical depression drawn from rich administrative longitudinal individual-level data from a large municipality in Spain. This approach allows estimating the causal impact of a type-2 diabetes diagnosis on clinica ldepression.

RESULTS

We find that overall a type-2 diabetes diagnosis increases the probability of becoming depressed, however this effect appears to be driven mostly by women, and in particular those who are relatively younger and obese. Results also appear to differ by changes in lifestyle induced by the diabetes diagnosis: while women who did not lose weight are more likely to develop depression, men who did lose weight present a reduced probability of being depressed. Results are robust to alternative parametric and non-parametric specifications and placebo tests.

CONCLUSIONS

The study provides novel empirical evidence on the causal impact of health information on mental health, shedding light on gender-based differences in such effects and potential mechanisms through changes in lifestyle behaviours.

Brief intervention to enhance cessation of smokeless tobacco use in newly diagnosed patients with head and neck cancers: A randomized controlled trial in patient-relative dyads

Introduction

Tobacco use is a major causative factor for head and neck cancers (HNC). Continued use of tobacco even after cancer diagnosis is common and is associated with all-cause and cancer-specific mortality, cancer recurrence and poor treatment response. Evidence suggests that behavioral interventions, help achieve greater smoking cessation rates in HNC patients. However, intervention studies focussed on HNC patients using smokeless tobacco, which is more common than smoking in India, are sparse.

Materials and Methods

We conducted a parallel arm randomized controlled trial (RCT) on dyads of patients with recently diagnosed HNC and a close relative. The experimental arm received a brief tobacco cessation intervention (BTCI) and the control arm received treatment as usual (TAU); 27 and 25 dyads in each arm completed the trial.

Results

Overall for the dyads using SLT, the relative risk of continuing to use SLT was 3.23 times higher (odds ratio = 7.01) if BTCI was not undertaken at one-month follow-up and 4.43 times higher (odds ratio = 8.65) at 3-months follow-up. For patients only, the relative risk of continuing to use SLT at one-month and 3-months follow-ups was 4.99 and 12.04 times higher, respectively, if BTCI was not undertaken. For relatives only, the corresponding relative risk values were 2.14 and 2.2.

Conclusion

We conclude that BTCI delivered to patient-relative dyads, compared to TAU, is effective in enhancing the discontinuation rates of the use of SLT in newly diagnosed patients with HNC. This form of intervention is significantly effective for discontinuing SLT use in the relatives too.

Efficacy of smartphone applications to help cancer patients quit smoking: Protocol of the Quit2Heal randomized controlled trial

Cigarette smoking is highly prevalent among cancer patients in the United States (US), with up to half of cancer patients smoking at the time of their initial cancer diagnosis. However, evidence-based cessation programs are rarely implemented in oncology care, and smoking is not consistently treated in cancer treatment settings. Consequently, there is an urgent need for accessible and efficacious cessation treatments that are uniquely tailored to the needs of cancer patients. Here we describe the design and implementation of a randomized controlled trial (RCT) testing the efficacy of a smartphone app (Quit2Heal) versus a US Clinical Practice Guidelines-based app (QuitGuide) for smoking cessation among a planned sample of 422 cancer patients. Quit2Heal is designed to address cancer-related shame, stigma, depression, anxiety, and knowledge about the consequences of smoking/quitting. Quit2Heal is based on the principles of Acceptance and Commitment Therapy, a behavioral therapy that teaches skills for accepting cravings to smoke without smoking, values-driven motivation to quit, and preventing relapse. The primary aim of the RCT is to determine whether Quit2Heal has significantly higher self-reported 30-day point prevalence abstinence at 12 months relative to QuitGuide. The trial will also determine whether Quit2Heal's effect on cessation is (1) mediated by improvements in cancer-related shame, stigma, depression, anxiety, and knowledge about the consequences of smoking/quitting; and (2) moderated by baseline factors (e.g., cancer type, stage, time since diagnosis). If successful, Quit2Heal will offer a more efficacious, broadly scalable smoking cessation treatment that could be implemented alongside existing oncology care, thereby improving cancer outcomes.

Factors associated with successful smoking cessation in men with or without cardiovascular disease or cancer: Nationwide Korean population analysis

INTRODUCTION

This study was conducted to explore factors associated with smoking cessation in male smokers with cardiovascular disease (CVD) or cancer, the two leading causes of death worldwide, and to compare them with quitting factors in smokers without the two diseases.

METHODS

This is a secondary dataset analysis of the Korea National Health and Nutrition Examination Survey (KNHANES), nationally representative data from 2008-2019 (excluding 2013-2014), and included 12998 men without CVD or cancer (group without CVD or cancer), 1027 men with CVD (CVD group), and 616 men with cancer (cancer group). A Wald test with multiple logistic regression analysis was conducted.

RESULTS

The quitting success rates in the CVD and cancer groups were consistently higher than those in the group without CVD or cancer. Old age and willpower in the CVD group, and old age and being married in the cancer group were associated with quitting success. Secondhand smoking and methods of quitting other than willpower were related to quitting failure in both groups. When interaction effects between the groups were examined, household income was the only factor associated with successful cessation in the group without CVD or cancer (AOR=1.17, 1.18, and 1.40, among the second, third, and fourth highest income quartiles, respectively; p for interaction=0.023). Higher smoking amounts (AOR=0.85; p<0.001) and poor health perception (AOR=0.64; p=0.035) were associated with quitting failure in the group without CVD or cancer. However, no significant factor was detected related to smoking cessation in both the CVD and cancer groups when the interaction effect was investigated.

CONCLUSIONS

The quitting success rates in the CVD and cancer groups were higher, but no disease-specific quitting factors were identified. Therefore, being diagnosed with CVD or cancer itself could be inferred as a motive for quitting smoking.

Association of Pack-Years of Cigarette Smoking With Survival and Tumor Progression Among Patients Treated With Chemoradiation for Head and Neck Cancer

IMPORTANCE

After 10 pack-years of smoking was initially established as a threshold for risk stratification, subsequent clinical trials incorporated it to identify candidates for treatment deintensification. However, several recent studies were unable to validate this threshold externally, and the threshold for smoking exposure remains unclear.

OBJECTIVE

To estimate the threshold of pack-years of smoking associated with survival and tumor recurrence among patients with head and neck cancer.

DESIGN, SETTING, AND PARTICIPANTS

This single-institution, cohort study included patients with nonmetastatic head and neck cancer receiving chemoradiation from January 2005 to April 2021. Data were analyzed from January to April 2022.

EXPOSURES

Heavy vs light smoking using 22 pack-years as a threshold based on maximizing log-rank test statistic.

MAIN OUTCOMES AND MEASURES

Overall survival (OS), progression-free survival (PFS), locoregional failure (LRF), and distant failure (DF).

RESULTS

A total of 518 patients (427 male [82.4%]; median [IQR] age, 61 [55-66] years) were included. Median (IQR) follow-up was 44.1 (22.3-72.8) months. A nonlinear Cox regression model using restricted cubic splines showed continuous worsening of OS and PFS outcomes as pack-years of smoking increased. The threshold of pack-years to estimate OS and PFS was 22. Cox multivariable analysis (MVA) showed that more than 22 pack-years was associated with worse OS (adjusted hazard ratio [aHR] 1.57; 95% CI, 1.11-2.22; P = .01) and PFS (aHR, 1.38; 95% CI, 1.00-1.89; P = .048). On Fine-Gray MVA, heavy smokers were associated with DF (aHR, 1.71; 95% CI, 1.02-2.88; P = .04), but not LRF (aHR, 1.07; 95% CI, 0.61-1.87; P = .82). When 10 pack-years of smoking were used as a threshold, there was no association for OS (aHR, 1.23; 95% CI, 0.83-1.81; P = .30), PFS (aHR, 1.11; 95% CI, 0.78-1.57; P = .56), LRF (aHR, 1.19; 95% CI, 0.64-2.21; P = .58), and DF (aHR, 1.45; 95% CI, 0.82-2.56; P = .20). Current smoking was associated with worse OS and PFS only among human papillomavirus (HPV)-positive tumors (OS: aHR, 2.81; 95% CI, 1.26-6.29; P = .01; PFS: aHR, 2.51; 95% CI, 1.22-5.14; P = .01).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients treated with definitive chemoradiation, 22 pack-years of smoking was associated with survival and distant metastasis outcomes. Current smoking status was associated with adverse outcomes only among patients with HPV-associated head and neck cancer.

Does health information affect lifestyle behaviours? The impact of a diabetes diagnosis

Despite an increasing interest in the effect of health information on health-behaviours, evidence on the causal impact of a diagnosis on lifestyle factors is still mixed and does not often account for long-term effects. We explore the role of health information in individual health-related decisions by identifying the causal impact of a type-2 diabetes diagnosis on body mass index (BMI) and lifestyle behaviours. We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value in the diagnosis of type-2 diabetes provided by a biomarker (glycated haemoglobin) drawn from unique administrative longitudinal data from Spain. We find that following a type-2 diabetes diagnosis individuals appear to reduce their weight in the short-term. Differently from previous studies, we also provide evidence of statistically significant long-term impacts of a type-2 diabetes diagnosis on BMI up to three years from the diagnosis. We do not find perceivable effects of a type-2 diabetes diagnosis on quitting smoking or drinking. Overall, health information appears to have a sustained causal impact on weight reduction, a key lifestyle and risk factor among individuals with type-2 diabetes.

Tobacco cessation after head and neck cancer diagnosis is an independent predictor of treatment response and long-term survival

Head and neck squamous cell carcinoma (HNSCC) patients who are current smokers when diagnosed have inferior clinical outcomes compared to never-smokers or previous smokers. However, the impact of quitting after HNSCC diagnosis has not been quantified. In this retrospective, case-control study (n = 134), the odds of complete response to first-line therapy were 3.7 times higher among smokers at diagnosis who quit before treatment initiation (quitters; n = 55) than among those continuing to smoke (p = 0.03). Disease-free survival was also higher among quitters (aHR, 0.33; 95 % CI, 0.12-0.90; p = 0.029). Quitters were 67 % less likely to die of all causes than active smokers (aHR, 0.33; 95 % CI, 0.15-0.71; p = 0.004). These data show for the first time that, smoking cessation after HNSCC diagnosis is predictive of higher therapy efficacy and long-term survival.

A Daily Assessment Study of Smoking Cessation After a Head and Neck Cancer Diagnosis

INTRODUCTION

This intensive longitudinal study describes key events in the process of smoking cessation after a new head and neck cancer (HNC) diagnosis. Prior longitudinal studies show some cancer patients quit, while others continue to smoke, but details about the pattern in which these discrete outcomes arise are scarce. This study is meant to help rectify this gap in the literature.

AIMS AND METHODS

Participants were 42 HNC patients who reported current smoking at enrollment. Participants were recruited from an outpatient oncology clinic and completed a baseline questionnaire prior to begin a 30-day daily assessment.

RESULTS

Few participants (9.52%) achieved 30-day continuous abstinence from smoking. On average, participants reported 9.64 ± 11.93 total days of abstinence. Nearly, all (94.44%, n = 34) participants made at least one quit attempt, with an average of 16.94 ± 11.30 quit attempt days. Fewer participants were able to achieve a 24-hour quit attempt (52.78%, n = 19), with a corresponding average of 5.50 ± 8.69 24-hour days. The median time to first 24-hour quit attempt was 13 days after enrollment. Based on smoking behavioral patterns, participants were categorized into five groups, the most common being "persistent attempters," which involved unsuccessful quit attempts throughout the study. Only 45% of participants (n = 19) used evidence-based treatment, the most common being cessation medication.

CONCLUSIONS

This intensive longitudinal study found that cancer diagnosis can spur a lot of efforts to quit smoking. Unfortunately, this study suggests that many quit attempts are short lived, possibly a result of an absence or insufficient use of evidence-based treatments.

IMPLICATIONS

For adults who are current smokers at the time of cancer diagnosis, there is a high likelihood of persistent cigarette smoking and use of other tobacco products in the weeks and months after a cancer diagnosis. Furthermore, this study shows that while a lot of quit attempts may occur, few are successful, which may be partly attributable to the low use of evidence-based tobacco treatment. Future research with cancer patients should aim to identify predictors of quit attempts and abstinence as well as treatment utilization.

Smoking cessation after cancer diagnosis reduces the risk of severe cancer pain: A longitudinal cohort study

Background

Whether abstinence from smoking among cancer patients reduces cancer pain is still unclear. Opioids can act as a surrogate index for evaluating the incidence of severe cancer pain in countries where opioid abuse is infrequent. This study aimed to investigate whether changed smoking behavior after cancer diagnosis influences the incidence of severe cancer pain as determined by strong opioid use.

Methods

Using a large Japanese insurance claims database (n = 4,797,329), we selected 794,702 insured employees whose annual health checkup data could be confirmed ≥6 times between January 2009 and December 2018. We selected 591 study subjects from 3,256 employees who were diagnosed with cancer pain and had health checkup data at the year of cancer pain diagnosis.

Results

A significantly greater proportion of patients who continued smoking after cancer diagnosis (“current smoker”, n = 133) received strong opioids (36.8%) compared with patients who had never smoked or had stopped before cancer diagnosis (“non-smoker”, n = 383, 20.6%; p<0.05) but also compared with patients who had quit smoking after cancer diagnosis (“abstainer:”, n = 75, 24.0%; p<0.05). In multivariable Cox proportional hazards regression analysis, abstainers had a significantly lower risk of receiving strong opioids than current smokers (hazard ratio: 0.57, 95% CI: 0.328 to 0.997). These findings were consistent across multiple sensitivity analyses.

Conclusion

Our study demonstrated that patients who quit smoking after cancer diagnosis have a lower risk of severe cancer pain. This information adds clinical incentives for improving quality of life among those who smoked at the time of cancer diagnosis.

Germline Pathogenic Variants Impact Clinicopathology of Advanced Lung Cancer

BACKGROUND

The genetic factors that modulate risk for developing lung cancer have not been fully defined. Here, we sought to determine the prevalence and clinical significance of germline pathogenic/likely pathogenic variants (PV) in patients with advanced lung cancer.

METHODS

We studied clinical and tumor characteristics of germline PV in 5,118 patients who underwent prospective genomic profiling using paired tumor-normal tissue samples in 468 cancer genes.

RESULTS

Germline PV in high/moderate-penetrance genes were observed in 222 (4.3%) patients; of these, 193 patients had PV in DNA damage repair (DDR) pathway genes including BRCA2 (n = 54), CHEK2 (n = 30), and ATM (n = 26) that showed high rate of biallelic inactivation in tumors. BRCA2 heterozygotes with lung adenocarcinoma were more likely to be never smokers and had improved survival compared with noncarriers. Fourteen patients with germline PV in lung cancer predisposing genes (TP53, EGFR, BAP1, and MEN1) were diagnosed at younger age compared with noncarriers, and of tumor suppressors, 75% demonstrated biallelic inactivation in tumors. A significantly higher proportion of germline PV in high/moderate-penetrance genes were detected in high-risk patients who had either a family history of any cancer, multiple primary tumors, or early age at diagnosis compared with unselected patients (10.5% vs. 4.1%; P = 1.7e-04).

CONCLUSIONS

These data underscore the biological and clinical importance of germline mutations in highly penetrant DDR genes as a risk factor for lung cancer.

IMPACT

The family members of lung cancer patients harboring PV in cancer predisposing genes should be referred for genetic counseling and may benefit from proactive surveillance.

Problem alcohol and tobacco use in head and neck cancer patients at diagnosis: associations with health-related quality of life

Purpose

Problem alcohol and tobacco use in patients with head and neck cancer (HNC) frequently co-occur and each are associated with poor outcomes including health-related quality of life (HRQOL). The purpose of this descriptive exploratory study was to identify the prevalence of these co-occurring behaviors and associations with HNC-specific HRQOL within the first year of diagnosis in a large sample of patients with HNC.

Methods

Cross-sectional study examined prevalence of co-occurring problem alcohol and tobacco use at diagnosis in a large sample of patients with HNC (N = 1327). Problem alcohol use was assessed using the Short Michigan Alcoholism Screening Test (SMAST); patients were classified as current/previous/never smokers based on self-reported tobacco use. HNC-specific HRQOL was assessed using the Head and Neck Cancer Inventory (HNCI), measured at diagnosis and 3 and 12 months postdiagnosis.

Results

Three hundred twenty-five of 1327 (24.5%) scored 3 + on the SMAST at diagnosis, suggesting problem alcohol use and nearly 30% (28.4%) were current smokers. Of those with problem alcohol use, 173 (53.2%) were also current smokers. In total, 173 of 1327 (13.0%) exhibited both behaviors at diagnosis. Covariate-adjusted mean HNCI scores suggest that patients classified as both problem drinkers and current smokers have lower HRQOL scores during the first year postdiagnosis in multiple HNC-specific domains.

Conclusion

HNC patients should be screened for alcohol and tobacco use at diagnosis. Multimodal behavioral health interventions may provide one avenue for improved access and outcomes, particularly for patients at distance, and deserve further study in HNC.

Tobacco Use and Tobacco Treatment Referral Response of Patients With Cancer: Implementation Outcomes at a National Cancer Institute-Designated Cancer Center

PURPOSE

Smoking after a cancer diagnosis is linked to cancer-specific and all-cause mortality, among other adverse outcomes. Yet, 10%-20% of US cancer survivors are current smokers. Implementation of evidence-based tobacco treatment in cancer care facilities is widely recommended, yet rarely accomplished. This study focuses on the early outcomes of a population-based tobacco treatment program integrated within an National Cancer Institute-designated cancer center.

METHODS AND MATERIALS

The sample consists of 26,365 patients seen at the cancer center during the first 18 months of program implementation. The study is a retrospective chart review of patients' tobacco use and, among current users, patients' treatment referral response.

RESULTS

More than 99% of patients were screened for tobacco use. Current (past month) use was observed in 21.05% of patients; cigarettes were the most popular product. Only 17.22% of current users accepted a referral for tobacco treatment; among current users who declined, the majority were not ready to quit (65.84%) or wanted to quit on their own (27.01%). Multiple demographic variables were associated with tobacco use and treatment referral response outcomes.

CONCLUSION

Despite cancer diagnosis presenting a teachable moment for tobacco cessation, patients with cancer may not be ready to quit or engage with treatment. Clinically proven strategies to increase motivation, prompt quit attempts, and encourage treatment use should be key components of tobacco treatment delivery to patients with cancer.

A descriptive study of cervical cancer survivors' persistent smoking behavior and perceived barriers to quitting

OBJECTIVE

Cervical cancer survivors (CCS) tend to smoke cigarettes at rates much higher than other cancer survivors and women in the general population. However, few studies take a deep dive into the smoking behavior of cervical cancer survivors and none focus on the barriers they experience related to smoking cessation. This study aimed to describe CCS' tobacco use characteristics, quit attempts, and barriers to quit success.

METHOD

In a concurrent mixed-method design, 50 CCS (94% White nonHispanic) who were diagnosed in the past 5 years and were current smokers at diagnosis provided data via standardized questionnaire and semi-structured interview.

RESULTS

More than three-quarters of participants were current smokers at the time of study participation, 25.6% of whom also reported noncigarette tobacco use (e.g., electronic cigarette, cigar, snus). Seventy percent of participants reported making at least one 24 hr quit attempt postdiagnosis, with 61.5% of current smokers preferring to quit without professional advice or counseling and 51.3% preferring to quit without medication assistance. Four themes emerged regarding barriers to smoking cessation: motivation and readiness; confidence and uncertainty; triggers; and social and environmental factors.

CONCLUSIONS

The rate of smoking in CCS is remarkably high, which may partly be explained by negative attitudes toward and low use of evidence-based treatment as well as multi-level barriers to smoking cessation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Head and neck cancer survivorship consensus statement from the American Head and Neck Society

OBJECTIVES

To provide a consensus statement describing best practices and evidence regarding head and neck cancer survivorship.

METHODS

Key topics regarding head and neck cancer survivorship were identified by the multidisciplinary membership of the American Head and Neck Society Survivorship, Supportive Care & Rehabilitation Service. Guidelines were generated by combining expert opinion and a review of the literature and categorized by level of evidence.

RESULTS

Several areas regarding survivorship including dysphonia, dysphagia, fatigue, chronic pain, intimacy, the ability to return to work, financial toxicity, lymphedema, psycho-oncology, physical activity, and substance abuse were identified and discussed. Additionally, the group identified and described the role of key clinicians in survivorship including surgical, medical and radiation oncologists; dentists; primary care physicians; psychotherapists; as well as physical, occupational, speech, and respiratory therapists.

CONCLUSION

Head and neck cancer survivorship is complex and requires a multidisciplinary approach centered around patients and their caregivers. As survival related to head and neck cancer treatment improves, addressing post-treatment concerns appropriately is critically important to our patient's quality of life. There continues to be a need to define effective and efficient programs that can coordinate this multidisciplinary effort toward survivorship.

Radiation-Associated Sarcoma of the Head and Neck: Incidence, Latency, and Survival

OBJECTIVES/HYPOTHESIS

Radiation-associated sarcomas of the head and neck (RASHN) are known but rare sequelae after radiation for squamous cell carcinoma. The purpose of this study was to characterize RASHN, estimate the risk of RASHN in head and neck squamous cell patients after therapeutic radiation, and compare their survival to that of patients with de novo sarcomas of the head and neck (dnSHN).

STUDY DESIGN

Retrospective database analysis.

METHODS

RASHN and dnSHN cases were collected from the Surveillance, Epidemiology, and End Results Database to identify risk factors and calculate incidence and latency. Survival was compared between RASHN and dnSHN.

RESULTS

The risk of RASHN was 20.0 per 100,000 person-years. The average latency period was 124.2 months (range 38-329). The cumulative incidence of RASHN at 20 years was 0.13%. Oral cavity and oropharynx primaries demonstrate increased risk. Five-year overall survival of RASHN was 22.4% compared to 64.5% for dnSHN.

CONCLUSIONS

RASHN are confirmed to be rare. RASHN have poor overall survival and worse survival compared to dnSHN. The impact of intensity-modulated radiation therapy protocols on this risk is unknown. Modifiable risk factors of smoking and alcohol consumption continue to dwarf radiation therapy as risk factors of second primary head and neck cancers.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Comparison of physical and psychosocial function post-treatment among oral cancer patients with low-to-moderate and high nicotine dependence

PURPOSE

After suddenly stopping smoking after an initial oral cancer (OC) diagnosis, patients may restart smoking and nicotine dependence. This study sought to identify factors associated with high nicotine dependence in OC patients who restarted smoking post-treatment.

DESIGN

A cross-sectional study.

METHODS

A group of 220 OC patients who restarted smoking post-treatment were recruited from the outpatient radiation department of a single cancer center in northern Taiwan. Demographic and clinical characteristics were recorded, and patients were assessed for nicotine and smoking dependence, physical activity and function, socio-emotional function, social support, and depression.

RESULTS

Among patients who restarted smoking after treatment for OC, 75.9% reported low-to-moderate dependence on smoking, while 24.1% reported high nicotine dependence. Factors associated with high nicotine dependence included higher incidence of smoking per day, greater dependence on smoking, less physical activity per week, and poorer social-emotional function. Those highly dependent on nicotine were younger, unmarried, had less education, and had begun smoking earlier than those with low-to-moderate nicotine dependence.

CONCLUSIONS

The amount of smoking per day, greater smoking behavioral dependence, less physical activity per week, and worse social-emotional function affected high nicotine dependence.

CLINICAL RELEVANCE

Smoking cessation training and counseling for OC patients may help them better control their use of tobacco after treatment.

Therapeutic radiographers supporting individuals undergoing radiotherapy to stop smoking: Testing a training resource in clinical practice

INTRODUCTION

This study developed and piloted the first online training package to support implementation and delivery of brief smoking cessation interventions for therapeutic radiographers in four radiotherapy departments in England.

METHODS

A previously reported systematic literature review and data analysis from the previously reported pre-focus group questionnaire and focus groups enabled the development of an online training package. The questionnaire was repeated by the participating therapeutic radiographers following completion of the training resource (n = 31). The results of the comparative questions from the pre and post questionnaires were analysed using the Statistical Package for Social Sciences (SPSS Version 24).

RESULTS

In total, 43 therapeutic radiographer participants completed the pre-questionnaire and 31 participants continued to complete the post questionnaire, having completed the online training package. The previously conducted focus groups identified several barriers to the delivery of smoking cessation, that were addressed through the development of an online training package. Following the completion of the training; therapeutic radiographers had increased knowledge and confidence regarding smoking cessation, the number of therapeutic radiographers who believe that smoking cessation is part of their role increased and therapeutic radiographers more routinely have conversations about smoking cessation.

CONCLUSION

The training resource improved therapeutic radiographers' knowledge and confidence and increased awareness of the role of the therapeutic radiographer in the provision of smoking cessation interventions. Challenges remain that continue to prevent some therapeutic radiographers from delivering smoking cessation interventions and strong leadership and implementation of strategy and guidance is essential to ensure wider implementation. Recording and measuring impact of interventions remains an area to be addressed, alongside cultural changes and reassurance around the therapeutic relationship.

IMPLICATIONS FOR PRACTICE

This training tool has proven to be effective in the sample within this study and should be disseminated and evaluated more widely across radiotherapy provision within the United Kingdom.

Substance use and mental health burden in head and neck and other cancer survivors: A National Health Interview Survey analysis

BACKGROUND

Tobacco dependence, alcohol abuse, depression, distress, and other adverse patient-level influences are common in head and neck cancer (HNC) survivors. Their interrelatedness and precise burden in comparison with survivors of other cancers are poorly understood.

METHODS

National Health Interview Survey data from 1997 to 2016 were pooled. The prevalence of adverse patient-level influences among HNC survivors and matched survivors of other cancers were compared using descriptive statistics. Multivariable logistic regressions evaluating covariate associations with the primary study outcomes were performed. These included 1) current cigarette smoking and/or heavy alcohol use (>14 drinks per week) and 2) high mental health burden (severe psychological distress [Kessler Index ≥ 13] and/or frequent depressive/anxiety symptoms).

RESULTS

In all, 918 HNC survivors and 3672 matched survivors of other cancers were identified. Compared with other cancer survivors, more HNC survivors were current smokers and/or heavy drinkers (24.6% [95% CI, 21.5%-27.7%] vs 18.0% [95% CI, 16.6%-19.4%]) and exhibited a high mental health burden (18.6% [95% CI, 15.7%-21.5%] vs 13.0% [95% CI, 11.7%-14.3%]). In multivariable analyses, 1) a high mental health burden predicted for smoking and/or heavy drinking (odds ratio [OR], 1.4; 95% CI, 1.0-1.9), and 2) current cigarette smoking predicted for a high mental health burden (OR, 1.7; 95% CI, 1.2-2.3). Furthermore, nonpartnered marital status and uninsured/Medicaid insurance status were significantly associated with both cigarette smoking and/or heavy alcohol use (ORs, 1.9 [95% CI, 1.4-2.5] and 1.5 [95% CI, 1.0-2.1], respectively) and a high mental health burden (ORs, 1.4 [95% CI, 1.1 -1.8] and 3.0 [95% CI, 2.2-4.2], respectively).

CONCLUSIONS

Stakeholders should allocate greater supportive care resources to HNC survivors. The interdependence of substance abuse, adverse mental health symptoms, and other adverse patient-level influences requires development of novel, multimodal survivorship care interventions.

Management of Oral Potentially Malignant Disorders

Patients with oral potentially malignant disorders (OPMDs), including oral leukoplakia and erythroplakia, proliferative verrucous leukoplakia, oral submucous fibrosis, and oral lichen planus/lichenoid lesions can be challenging to manage. A small proportion will undergo cancer development and determining a patient's cancer risk is key to making management decisions. Yet, our understanding of the natural history of OPMDs has not been fully elucidated, and a precision approach based on the integration of numerous predictive markers has not been validated by prospective studies. Evidence-based health promotion by clinicians and healthcare systems is not embraced universally. Medical and surgical interventions evaluated by rigorous research measuring important endpoints, such as cancer development, mortality, or survival are difficult and expensive to run. Most of these studies employ non-ideal surrogate endpoints and have deep methodologic flaws. Diagnostic criteria for enrolling research subjects are not uniform, and patients with the highest risk for cancer development comprise small proportions of those enrolled. Few studies explore quality of life and patient preferences. It is time to rethink how we approach the management of these patients, across each OPMD, and considering the healthcare infrastructure and cost effectiveness. Global networks with well-characterized patient populations with OPMDs and well-designed interventional trials using validated outcome measures are needed.

The State of the Science on Cancer Diagnosis as a "Teachable Moment" for Smoking Cessation: A Scoping Review

Theoretically, cancer diagnosis has potential to spur health behavior changes in physical activity, diet, substance use, medication adherence and the like. The Teachable Moment heuristic is a parsimonious, transtheoretical framework for understanding the conditions under which behavior change might occur, with constructs that include affective, cognitive, and social factors. Application of the Teachable Moment to smoking cessation after cancer diagnosis might aid selection of predictors in observational studies and inform how to optimally design interventions to promote quit attempts and sustain abstinence, as many smoking cessation interventions for cancer survivors do not yield positive outcomes. This scoping review of 47 studies that span nearly 20 years of literature examines measurement of the Teachable Moment constructs and what empirical support they have in explaining cancer survivors' smoking behavior. From this review, it appears the construct of affective response is more widely explored than risk perceptions, social role, and self-concept. Strong, negative affective responses (e.g., anxiety, general distress) may be a powerful contributor to continued smoking after cancer diagnosis. Risk perceptions may also play a role in smoking behavior, such that never and former smokers espouse stronger perceptions of smoking-related risks than current smokers. Finally, due to a paucity of studies, the role of cancer survivors' self-concept (e.g., identity as a "cancer survivor") and changes in their social role (e.g., employee, athlete) are unclear contributors to their smoking behavior. In summary, the Teachable Moment holds promise in its application to smoking cessation after cancer diagnosis, though more direct research is needed.

It Takes Two to Tango: Patients' and Providers' Perspectives in Tobacco Cessation and Head/Neck Cancer

BACKGROUND

Tobacco cessation among patients with head/neck cancer continues to be challenging despite evidence that cessation improves treatment outcomes. The purpose of this study was to understand barriers/facilitators to tobacco cessation among patients with head/neck cancer and health care providers and to obtain perspectives toward the development of a patient-centered tobacco cessation intervention.

MATERIALS AND METHODS

In-depth qualitative interviews with 10 health care providers and 21 patients with head/neck cancer (12 inpatients and 9 outpatients) who were current or former smokers.

RESULTS

Health was a common motivator to quit among patients. Although most patients indicated that their health care provider asked and advised them to quit, they were unaware of cessation resources. Suggestions for a tobacco cessation program included involvement of former smokers, health care provider involvement/counseling, supporting written materials, and incorporating follow-up and family support. Health care providers identified patients' anger/frustration associated with the disease, social/demographic issues, and poor quality of life as the three most frequent challenges in treating patients. Although all providers reported asking about tobacco use, 70% emphasized a lack of formal training in tobacco cessation and lack of time. Their suggestions for a cessation program included having a "quarterback" responsible for this component with support from the entire health care team and continuity between outpatient and inpatient services to promote cessation, prevent relapse, and highlight the importance of follow-up and social support.

CONCLUSION

There is great interest and need, both from patients and providers, for tobacco cessation services in the oncology setting tailored for patients with head/neck cancer in the context of cancer care.

IMPLICATIONS FOR PRACTICE

Although the combination of pharmacotherapy and cognitive-behavioral intervention is the standard evidence-based treatment for tobacco dependence, it must be adapted to meet the needs and wants of patients and providers to be effective. This study provides an in-depth examination of such needs among patients with head and neck cancer and providers in the context of cancer care. Providers and patients emphasized the need of having a trained health care provider dedicated to providing tobacco cessation through seamless integration between outpatient and inpatient services as well as follow-up with an emphasis on family involvement throughout the process.

E-cigarette and cigarette use among cancer survivors versus general population: a case-control study in Korea

PURPOSE

Although successful smoking cessation after cancer diagnosis is important, research on e-cigarette use and smoking behavior among cancer survivors (CS) is limited. This study compared cigarette and e-cigarette use among CS and non-cancer populations in Korea.

METHODS

This study analyzed the 2013-2018 National Health and Nutrition Survey data to investigate e-cigarette use and smoking behavior among Korean CS. The data were categorized into 1260 CS and 5040 non-cancer populations using the propensity score matching method. A multiple logistic regression was conducted among CS who previously used cigarettes or e-cigarettes to evaluate factors influencing successful cessation.

RESULTS

Regarding conventional smoking, the proportion of ex-smokers was higher (25.2% versus 19.9%) than current smokers (6.7% versus 10.6%) in the CS group than in the propensity matched non-cancer population (PMNCP) (p < 0.001). However, ever use of e-cigarettes did not differ between them (2.4% versus 2.7%, p = 0.529). Successful cessation, defined as not using either cigarettes or e-cigarettes, correlated with problem drinking (OR 0.442, 95% CI 0.207-0.940), depression (OR 0.276, 95% CI 0.087-0.872), and cancer sites. CS of stomach, liver, colorectal, and lung cancer maintained higher successful smoking cessation rates than PMNCP.

CONCLUSIONS

Korean CS had a higher cessation rate than PMNCP regarding conventional smoking; however, there was no difference in e-cigarette use.

IMPLICATIONS FOR CANCER SURVIVORS

In Korea, some CS continue to use e-cigarettes, and physicians should focus on helping them quit. Individualized and timely interventions should be provided for both cigarette and e-cigarette users, considering factors influencing successful cessation.

Electronic cigarette aerosols alter the expression of cisplatin transporters and increase drug resistance in oral cancer cells

Tobacco smoking is the leading preventable cause of cancer. Moreover, continued smoking during cancer therapy reduces overall survival. Aware of the negative consequences of tobacco smoking and the challenges of smoking cessation, cancer patients are inquiring whether they should switch to electronic cigarettes (e-cigarettes). To obtain evidence-based data to inform this decision, we examined the effects of e-cigarette aerosol exposure on cisplatin resistance in head and neck cancer cells. Our results show that cancer cells exposed to e-cigarette aerosol extracts and treated with cisplatin have a significant decrease in cell death, increase in viability, and increase in clonogenic survival when compared to non-exposed cells. Moreover, exposure to e-cigarette aerosol extracts increased the concentration of cisplatin needed to induce a 50% reduction in cell growth (IC50) in a nicotine-independent manner. Tobacco smoke extracts induced similar increases in cisplatin resistance. Changes in the expression of drug influx and efflux transporters, rather than activation of cell growth-promoting pathways or DNA damage repair, contribute to e-cigarette induced cisplatin resistance. These results suggest that like combustible tobacco, e-cigarette use might increase chemotherapy resistance, and emphasize the urgent need for rigorous evaluation of e-cigarettes health effects to ensure evidence-based public health policies.

Primary and Secondary Prevention of Lung Cancer: Tobacco Treatment

Tobacco dependence is the most consequential target to reduce the burden of lung cancer worldwide. Quitting after a cancer diagnosis can improve cancer prognosis, overall health, and quality of life. Several oncology professional organizations have issued guidelines stressing the importance of tobacco treatment for patients with cancer. Providing tobacco treatment in the context of lung cancer screening is another opportunity to further reduce death from lung cancer. In this review, the authors describe the current state of tobacco dependence treatment focusing on new paradigms and approaches and their particular relevance for persons at risk or on treatment for lung cancer.

Cigarette-smoking characteristics and interest in cessation in patients with head-and-neck cancer

Purpose

Many patients diagnosed with head-and-neck cancer are current or former smokers. Despite the well-known adverse effects of smoking, continuation of smoking during cancer treatment is associated with reduced efficacy of that treatment and with cancer recurrence. In the present study, we examined smoking characteristics in patients with head-and-neck cancer near the time of cancer treatment.

Methods

A prospective cohort of patients with head-and-neck cancer who attended a dental oncology clinic before receiving cancer treatment at a regional cancer centre were invited to participate in a study that involved completing an interviewer-administered questionnaire to assess smoking characteristics, intention to quit, motivation to quit, and strategies perceived to potentially aid in successful cessation.

Results

The study enrolled 493 ever-smokers, with a response rate of 96.1% and a self-reported current smoker rate of 37.1% (n = 183). Most of the current smokers reported high nicotine dependence, with 84.7% (n = 155) indicating a time to first cigarette of 30 minutes or less. Most had previously attempted to quit smoking (77.0%), and many had prior unsuccessful quit attempts before resuming smoking again. Most were interested in quitting smoking (85.8%), and many (70.5%) were seriously considering quitting smoking within the subsequent 30 days.

Conclusions

Patients with head-and-neck cancer reported high nicotine dependence and high interest in cessation opportunities near the time of treatment for cancer. Those results might provide support for provision of smoking cessation opportunities.

DNA Methylome Distinguishes Head and Neck Cancer from Potentially Malignant Oral Lesions and Healthy Oral Mucosa

There is a strong need to find new, good biomarkers of head and neck squamous cell carcinoma (HNSCC) because of the bad prognoses and high mortality rates. The aim of this study was to identify the potential biomarkers in HNSCC that have differences in their DNA methylome and potentially premalignant oral lesions, in comparison to healthy oral mucosa. In this study, 32 oral samples were tested: nine healthy oral mucosae, 13 HNSCC, and 10 oral lesions for DNA methylation by the Infinium MethylationEPIC BeadChip. Our findings showed that a panel of genes significantly hypermethylated in their promoters or specific sites in HNSCC samples in comparison to healthy oral samples, which are mainly oncogenes, receptor, and transcription factor genes, or genes included in cell cycle, transformation, apoptosis, and autophagy. A group of hypomethylated genes in HNSCC, in comparison to healthy oral mucosa, are mainly involved in the host immune response and transcriptional regulation. The results also showed significant differences in gene methylation between HNSCC and potentially premalignant oral lesions, as well as differently methylated genes that discriminate between oral lesions and healthy mucosa. The given methylation panels point to novel potential biomarkers for early diagnostics of HNSCC, as well as potentially premalignant oral lesions.

Impact of a tobacco treatment program on abstinence and survival rates among current smokers with head and neck squamous cell carcinoma

BACKGROUND

Approximately one quarter of head and neck cancer (HNC) patients smoke cigarettes at the time of diagnosis. Despite HNC guideline recommendations to treat tobacco dependence, the effectiveness of treatment in this population is poorly described.

METHODS

This retrospective cohort review evaluated 117 current smokers with p16-negative mucosal head and neck squamous cell carcinoma prospectively enrolled in a tobacco treatment program. Seven-day point prevalence tobacco abstinence rates at 9 months and survival outcomes were compared among abstinent and nonabstinent groups.

RESULTS

Median follow-up among survivors was 62.4 months. Forty percent of patients were abstinent at 9 months according to intention-to-treat analysis. After adjustment for age, comorbidity and site, abstinent stage I to II patients had a decreased risk of death compared to smoking stage I to II patients (HR 0.15, 95% CI 0.03-0.82).

CONCLUSIONS

High cohort abstinence rates and favorable survival among abstinent patients with early-stage HNC confirm the importance of tobacco dependence treatment in this population.

Smoking cessation prolongs survival in female cancer survivors - the Danish nurse cohort

PURPOSE

To explore smoking cessation between cancer survivors and cancer-free women, and the potential survival benefits from smoking cessation in cancer surviving women.

METHOD

We pooled 46,334 responses from the Danish Nurse Cohort. The cohort consists of female nurses, who were invited for surveys in 1993, 1999 and 2009. Participants were linked to nationwide registries on hospitalization, cause of death and migration through 2016. Odds for smoking cessation by cancer diagnosis were computed in propensity score matched logistic regression models, while survival by postdiagnosis smoking cessation was estimated in cox proportional hazards models.

RESULTS

Eligible for analysis were 7841 women (mean age = 56.7 years, SD ± 7.2), who were smokers at baseline and survived to the next follow-up survey. Of these, 545 women were diagnosed with cancer and matched by propensity score (1:2) with 1090 cancer-free women. Odds for smoking cessation were significantly higher in cancer-diagnosed women compared to their cancer-free peers (OR = 1.31, 95% CI: 1.06-1.61). Moreover, mortality risk was significantly lower among cancer survivors who stopped smoking (HR = 0.64, 95% CI: 0.46-0.91), compared to persistent smokers.

CONCLUSIONS

The results suggest considerable survival benefits from smoking cessation in cancer surviving female nurses, and that the time surrounding cancer diagnosis may serve as a teachable moment for smoking cessation. However, due to substantial methodological limitations embedded in the study, careful interpretation of the presented results is warranted. Future studies are needed to demonstrate the effects of diagnosis on smoking cessation as well as the effects of smoking cessation on survival in female cancer populations.

Smoking Behaviors in Survivors of Smoking-Related and Non-Smoking-Related Cancers

IMPORTANCE

The population of cancer survivors is rapidly growing in the US. Tobacco smoking is associated with many cancers; however, whether cigarette smoking behaviors among cancer survivors vary according to cancer type-that is, smoking-related cancers (SRCs) vs non-smoking-related cancers (NSRCs)-remains unclear.

OBJECTIVES

To examine cigarette smoking prevalence and behaviors (ie, continuing or quitting smoking) among cancer survivors and to compare them between survivors of SRCs and NSRCs.

DESIGN, SETTING, AND PARTICIPANTS

This study was a cross-sectional analysis of the 2017 National Health Interview Survey, a household survey of civilian US residents who were aged 18 years or older. The National Health Interview Survey is population based and is representative of the US population. Data analysis was performed from June to October 2019.

MAIN OUTCOMES AND MEASURES

The primary outcomes were prevalence of current cigarette smoking among cancer survivors and prevalence of continuing smoking and quitting smoking after a cancer diagnosis. Secondary outcomes included factors associated with continued smoking vs quitting smoking after a cancer diagnosis.

RESULTS

A total of 26 742 respondents (mean [SD] age, 50.97 [18.61] years; 14 646 women [51.76%]) to the 2017 National Health Interview Survey were included in this study. Of the 3068 individuals (9.42%) in the study population who had cancer, 589 (19.96%) were SRC survivors, 2297 (74.50%) were NSRC survivors, 168 (4.96%) were survivors of both SRC and NSRC, and the remaining 14 (0.58%) had missing information about the type of cancer. Four hundred forty-nine SRC survivors (54.08%) were women, compared with 1412 NSRC survivors (54.30%). Ninety-six SRC survivors (15.69%) and 151 NSRC survivors (7.99%) were younger than 45 years. Overall, 372 cancer survivors (13.16%) were current smokers. Current smoking prevalence was higher among survivors of SRCs (145 survivors [19.78%]) compared with NSRC survivors (251 survivors [10.63%]). Among cancer survivors, 309 current smokers at cancer diagnosis (43.96%) reported having successfully quit smoking and 372 (56.04%) reported continuing smoking. Among the continuing smokers, 176 (56.49%) reported an unsuccessful quit attempt in the last 12 months. After cancer diagnosis, SRC survivors had higher odds of continued smoking compared with NSRC survivors (odds ratio [OR], 2.10; 95% CI, 1.12-3.93; P = .02). Men (OR, 1.93; 95% CI, 1.05-3.57; P = .04), those with angina pectoris (OR, 5.40; 95% CI, 1.33-21.91; P = .02), and those with chronic bronchitis (OR, 2.55; 95% CI, 1.05-6.19; P = .04) had higher odds of continued smoking, whereas Hispanic participants (compared with non-Hispanic white participants: OR, 0.18; 95% CI, 0.05-0.68; P = .01) and married participants (compared with never married participants: OR, 0.33; 95% CI, 0.12-0.96; P = .04) had lower odds of continued smoking.

CONCLUSIONS AND RELEVANCE

These findings suggest that compared with NSRC survivors, SRC survivors may be at higher risk of being cigarette smokers at cancer diagnosis and of continuing smoking afterward. Although smoking cessation interventions are critically important for all cancer survivors, special efforts should target survivors of SRCs.

Using a Quitline to Deliver Opt-Out Smoking Cessation for Cancer Patients

PURPOSE

Although smoking by patients with cancer and survivors causes adverse outcomes, many patients with cancer do not receive access to evidence-based tobacco use treatment. The purpose of this article is to report on delivery of tobacco use treatment to patients with cancer using a state-supported Quitline.

METHODS

Statewide agencies in Michigan partnered with the Michigan Oncology Quality Consortium to develop and implement a clinical quality improvement initiative with the goal of addressing tobacco use by patients with cancer across Michigan oncology practices. The collaborative designed an opt-out approach for identifying tobacco users and referring them to the Michigan Tobacco Quitline (hereafter known as Quitline) within participating practices. As the initiative progressed, patients with cancer who were not referred through the initiative also became eligible for enrollment in the Quitline program.

RESULTS

A total of 4,347 patients with cancer enrolled in the Quitline between 2012 and 2017, and annual referrals from oncology practices increased from 364 (5% of Quitline participants) to 876 (17% of Quitline participants). The 2013-2016 Michigan Behavioral Risk Factor Surveillance System also demonstrated an increase from 60% to 80% of cancer survivors receiving smoking cessation resources. Of 3,892 patients with cancer who had Quitline follow-up data through 2017, 79% completed one or more counseling calls. The 6-month self-reported quit rate for patients with cancer assessed between 2013 and 2016 was 26%.

CONCLUSION

Using statewide resources to increase access to evidence-based smoking cessation assistance to patients with cancer is achievable. In an increasingly cost-conscious health care environment, collaborative initiatives that use or enhance existing resources should be considered and refined to deliver effective evidence-based care.

A Smartphone App Designed to Help Cancer Patients Stop Smoking: Results From a Pilot Randomized Trial on Feasibility, Acceptability, and Effectiveness

Background

Persistent smoking after a cancer diagnosis predicts worse treatment outcomes and mortality, but access to effective smoking cessation interventions is limited. Smartphone apps can address this problem by providing a highly accessible, low-cost smoking cessation intervention designed for patients with a recent cancer diagnosis.

Objective

This study aimed to summarize our development process and report the trial design, feasibility, participant acceptability, preliminary effectiveness, and impact on processes of change (eg, cancer stigma) of the first-known smoking cessation smartphone app targeted for cancer patients.

Methods

We used an agile, user-centered design framework to develop a fully automated smartphone app called Quit2Heal that provided skills training and stories from cancer survivors focusing on coping with internalized shame, cancer stigma, depression, and anxiety as core triggers of smoking. Quit2Heal was compared with the National Cancer Institute’s QuitGuide, a widely used stop smoking app for the general population, in a pilot double-blinded randomized trial with a 2-month follow-up period. Participants were 59 adult smokers diagnosed with cancer within the past 12 months and recruited through 2 cancer center care networks and social media over a 12-month period. The most common types of cancer diagnosed were lung (21/59, 36%) and breast (10/59, 17%) cancers. The 2-month follow-up survey retention rate was 92% (54/59) and did not differ by study arm (P=.15).

Results

Compared with QuitGuide participants, Quit2Heal participants were more satisfied with their assigned app (90% [19/21] for Quit2Heal vs 65% [17/26] for QuitGuide; P=.047) and were more likely to report that the app assigned to them was made for someone like them (86% [18/21] for Quit2Heal vs 62% [16/26] for QuitGuide; P=.04). Quit2Heal participants opened their app a greater number of times during the 2-month trial period, although this difference was not statistically significant (mean 10.0, SD 14.40 for Quit2Heal vs mean 6.1, SD 5.3 for QuitGuide; P=.33). Self-reported 30-day point prevalence quit rates at the 2-month follow-up were 20% (5/25) for Quit2Heal versus 7% (2/29) for QuitGuide (odds ratio 5.16, 95% CI 0.71-37.29; P=.10). Quit2Heal participants also showed greater improvement in internalized shame, cancer stigma, depression, and anxiety, although these were not statistically significant (all P>.05).

Conclusions

In a pilot randomized trial with a high short-term retention rate, Quit2Heal showed promising acceptability and effectiveness for helping cancer patients stop smoking. Testing in a full-scale randomized controlled trial with a longer follow-up period and a larger sample size is required to test the effectiveness, mediators, and moderators of this promising digital cessation intervention.

Trial Registration

ClinicalTrials.gov NCT03600038; https://clinicaltrials.gov/ct2/show/NCT03600038

Brief Intervention for Tobacco when Diagnosed with Oral Cancer (BITDOC): Study protocol of a randomized clinical trial studying efficacy of brief tobacco cessation intervention, Chhattisgarh, India

INTRODUCTION

Tobacco use is a major causative factor for cancer. Cessation programs along with diagnosis of cancer as a motivating factor may improve quitting rates in patients. This is a protocol of a study that aims to assess the efficacy of brief tobacco cessation intervention (compared to treatment as usual, TAU) on pattern and attitudes towards tobacco chewing in newly diagnosed head and neck cancer patients and their relatives.

METHODS

The proposed study will be conducted in two phases. Phase 1 will include 105 dyads of patients and relatives and shall assess patterns (amount, frequency, duration of use and dependence etc.) and knowledge and attitudes (quitting, continued use, health-behavioural modifications, long-term effects on treatment etc.) towards tobacco chewing in newly diagnosed head and neck cancer patients using smokeless tobacco and their relatives. Sample will be recruited from outpatients attending the ear, nose, throat and head and neck surgery department of a tertiary health care institute. Phase 2 will be a randomized trial that will compare the efficacy of the ‘Brief Intervention for Tobacco when Diagnosed with Oral Cancer’ (BITDOC) and TAU, and will include 27 dyads in each of the two groups. Intervention will be delivered in three sessions, based on the principles of motivational interviewing and the 3As model.

CONCLUSIONS

This study will help in the evaluation of the attitude towards smokeless tobacco (SLT) in a population that has faced the adverse consequences from its use and changes brought by a diagnosis of HNC. It will also help in developing a cost-effective model for promotion of smoking cessation.

Impact of oral and oropharyngeal cancer diagnosis on smoking cessation patients and cohabiting smokers

INTRODUCTION

Our aim was to determine the influence of oral and oropharyngeal (OOP) cancer diagnosis on smoking cessation in patients and/or cohabiting smokers. We also aimed to determine whether OOP cancer patients received smoking-cessation advice and evaluated the factors that were influential in aiding them to quit or decrease smoking.

METHODS

This study was conducted at King Fahad Medical City, Saudi Arabia from March 2015 to May 2017. A pre-validated self-administered questionnaire was administered to OOP cancer patients visiting the Dentistry and Head & Neck Oncology outpatient clinics. Sociodemographics and baseline information were obtained from electronic medical records. Data were collected from 203 patients; 88 were ever-smokers and 115 were never-smokers.

RESULTS

Among patients who were smoking at the time of the OOP cancer diagnosis, 47.7% continued to smoke after the diagnosis. OOP cancer diagnosis was influential in smoking cessation in ever-smoker patients and their cohabiting smokers. The apparent influence of OOP cancer diagnosis was different between cohabiting smokers of ever-smoker patients (n=21/25; 84%) and those of never-smokers (n=10/21; 47.6%). Former-smokers (n=16/19; 84.2%) were less likely to remember receiving smoking-cessation advice than current-smokers (n=17/39; 43.6%). Pressure from family and friends, adverse impact on cancer prognosis, and adverse impact of cancer treatment were influential factors for smoking cessation. Among treatment modalities, combined chemoradiotherapy had the greatest impact (n=10/21; 47.6%) on smoking cessation among patients who stated that oncology treatment was influential in causing them to quit or decrease smoking.

CONCLUSIONS

A substantial number of patients continued to smoke after the OOP cancer diagnosis; however, diagnosis facilitated smoking cessation in many cases. Current smoking status should be reviewed throughout the OOP cancer patient’s disease course, and smoking-cessation assistance should be provided where necessary.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR CANCER SURVIVORS

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

Tobacco smoking after diagnosis of cancer: clinical aspects

Tobacco smoking accounts for at least 30% of all cancer deaths and nearly 90% of lung cancer deaths. Smoking cessation significantly reduces the risk of developing tobacco-related malignancies. Smoking after cancer diagnosis is also associated with multiple risks, including worse tolerance of treatment, higher risk of a failure and second primary tumors, and poorer quality of life. Apart from disease site and stage, continued smoking is considered the strongest adverse predictor of survival in cancer patients. However, the benefits of smoking cessation are undervalued: many patients are not aware of harms related to continued tobacco use after cancer diagnosis. Furthermore, health care professionals often do not encourage their patients to quit, and do not provide tobacco cessation assistance for continuing tobacco users. Despite the apparent impact of tobacco use on treatment outcomes, data on current smoking status is only rarely captured in clinical trials This article reviews the most important clinical aspects of smoking after the diagnosis of cancer.

Screening, diagnosis, and long-term health outcomes in developing countries-The case of hypertension

Hypertension is a rapidly growing problem in developing countries. At the same time, due to its asymptomatic nature, the afflicted population is largely unaware of being hypertensive. Due to a lack of resources, routine medical exams are very rare in developing countries and many sick individuals remain undiagnosed. Using a large sample of hypertensive individuals from Indonesia, we show the importance of being diagnosed. Diagnosed individuals exhibit lower systolic and diastolic blood pressure, and overall lower probability of remaining hypertensive than undiagnosed individuals. We also show the main channels through which this is achieved: taking medication, routinely monitoring one’s blood pressure, and engaging in moderate physical activities. We also point to channels through which additional benefits could be realized, but that are currently ineffective: dietary changes and maintaining a healthy body weight. Combined, these results point to the importance of directing public policy towards addressing the under-diagnosis problem and educating the public of the benefits of adopting a healthy life-style.

Tobacco Use Assessment and Treatment in Cancer Patients: A Scoping Review of Oncology Care Clinician Adherence to Clinical Practice Guidelines in the U.S

BACKGROUND

Smoking after a cancer diagnosis negatively impacts health outcomes; smoking cessation improves symptoms, side effects, and overall prognosis. The Public Health Service and major oncology organizations have established guidelines for tobacco use treatment among cancer patients, including clinician assessment of tobacco use at each visit. Oncology care clinicians (OCCs) play important roles in this process (noted as the 5As: Asking about tobacco use, Advising users to quit, Assessing willingness to quit, Assisting in quit attempts, and Arranging follow-up contact). However, OCCs may not be using the "teachable moments" related to cancer diagnosis, treatment, and survivorship to provide cessation interventions.

MATERIALS AND METHODS

In this scoping literature review of articles from 2006 to 2017, we discuss (1) frequency and quality of OCCs' tobacco use assessments with cancer patients and survivors; (2) barriers to providing tobacco treatment for cancer patients; and (3) the efficacy and future of provider-level interventions to facilitate adherence to tobacco treatment guidelines.

RESULTS

OCCs are not adequately addressing smoking cessation with their patients. The reviewed studies indicate that although >75% assess tobacco use during an intake visit and >60% typically advise patients to quit, a substantially lower percentage recommend or arrange smoking cessation treatment or follow-up after a quit attempt. Less than 30% of OCCs report adequate training in cessation interventions.

CONCLUSION

Intervention trials focused on provider- and system-level change are needed to promote integration of evidence-based tobacco treatment into the oncology setting. Attention should be given to the barriers faced by OCCs when targeting interventions for the oncologic context.

IMPLICATIONS FOR PRACTICE

This article reviews the existing literature on the gap between best and current practices for tobacco use assessment and treatment in the oncologic context. It also identifies clinician- and system-level barriers that should be addressed in order to lessen this gap and provides suggestions that could be applied across different oncology practice settings to connect patients with tobacco use treatments that may improve overall survival and quality of life.

Smoking cessation among men following cancer diagnosis: a matched cohort study

PURPOSE

Cigarette smoking among cancer survivors increases the risk of recurrence and secondary cancers. We sought to investigate smoking cessation following diagnosis of cancer compared to those not diagnosed with cancer. We also investigated cessation following diagnosis of a smoking-related and non-smoking-related cancer separately.

METHODS

We conducted a matched cohort study within the Health Professionals Follow-Up Study (HPFS). We identified 566 men diagnosed with cancer who were current cigarette smokers at the time of diagnosis between 1986 and 2010 (exposed). Men diagnosed with cancer were age-matched 1:4 to men without a diagnosis of cancer who were also current cigarette smokers (unexposed). Multivariable conditional logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI) to evaluate the association between a cancer diagnosis and smoking cessation within 2 and 4 years post diagnosis adjusted for potential confounders, overall and for smoking-related and non-smoking-related cancers.

RESULTS

Of the men with cancer, 38% quit within 2 years and 42% within 4 years of diagnosis. Men diagnosed with cancer were more likely to quit smoking within 2 (OR = 2.5, 95% CI: 2.0-3.0) and 4 years (OR = 1.6, 95% CI: 1.3-2.0) post diagnosis, compared to matched men without cancer. The association was similar for smoking-related (OR = 3.4, 95%: 1.6-7.2) and non-smoking-related cancers (OR = 3.8, 95%: 2.8-5.2).

CONCLUSIONS

Men diagnosed with cancer were more likely to quit smoking compared to men not diagnosed with cancer. A cancer diagnosis may be a "teachable moment" in which strategies to promote smoking cessation for individuals diagnosed with smoking-related and non-smoking-related cancers should be investigated.

IMPLICATIONS FOR CANCER SURVIVORS

There is a continued need for the widespread implementation of cessation interventions for cancer survivors.