Smoking cessation potential among newly diagnosed cancer patients: a population-based study of the ten most common cancers in Massachusetts, USA, 2008-2013

PURPOSE

In cancer patients, cigarette smoking is causally linked with increased mortality. We examined the relationship between smoking status at the time of diagnosis and cancer mortality to help estimate the scope of smoking cessation services required to meet the needs of cancer patients.

METHODS

We studied the ten most common cancers in Massachusetts, 2008-2013 including 175,489 incident cases and used smoking status at the time of diagnosis to provide smoking prevalence. We calculated adjusted hazard ratios of all-cause mortality comparing smoker subgroups.

RESULTS

Smoking prevalence was more than threefold higher for lung cancer and more than twofold higher for head and neck cancer and bladder cancer than in the general population. Cancer cases who smoked at the time of diagnosis had a higher adjusted mortality rate than cancer cases who were former smokers. The three sites with the highest increased hazard ratios comparing current smokers with former smokers were cancers of the thyroid (HR = 1.67, 95% CI 1.14-2.45), head and neck (HR = 1.65, 95% CI 1.39-1.95), and prostate (HR = 1.60, 95% CI 1.36-1.90).

CONCLUSIONS

Smoking remains high among cancer patients. More widespread adoption of smoking cessation programs among cancer patients may play a substantial role in improving cancer morbidity and mortality.

Interventions for smoking cessation in people diagnosed with lung cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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.

The importance of incorporating smoking cessation into lung cancer screening

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

Smoking cessation and survival in lung, upper aero-digestive tract and bladder cancer: cohort study

BACKGROUND

The aim was to examine the association between smoking cessation and prognosis in smoking-related cancer as it is unclear that cessation reduces mortality.

METHODS

In this retrospective cohort study from 1999 to 2013, we assessed the association between cessation during the first year after diagnosis and all-cause and cancer-specific mortality.

RESULTS

Of 2882 lung, 757 upper aero-digestive tract (UAT) and 1733 bladder cancer patients 27%, 29% and 21% of lung, UAT and bladder cancer patients quit smoking. In lung cancer patients that quit, all-cause mortality was significantly lower (HR: 0.82 (0.74-0.92), while cancer-specific mortality (HR: 0.89 (0.76-1.04) and death due to index cancer (HR: 0.90 (0.77-1.05) were non-significantly lower. In UAT cancer, all-cause mortality (HR: 0.81 (0.58-1.14), cancer-specific mortality (HR: 0.84 (0.48-1.45), and death due to index cancer (HR: 0.75 (0.42-1.34) were non-significantly lower. There was no evidence of an association between quitting and mortality in bladder cancer. The HRs were 1.02 (0.81-1.30) for all-cause, 1.23 (0.81-1.86) for cancer specific, and 1.25 (0.71-2.20) for death due to index cancer. These showed a non-significantly lower risk in sensitivity analyses.

CONCLUSIONS

People with lung and possibly UAT cancer who quit smoking have a lower risk of mortality than people who continue smoking.

Tobacco assessment in completed lung cancer treatment trials

An effort over 3 years to conduct a data pooling project regarding the association between smoking and lung cancer treatment outcomes has shown that, of 32 completed studies of lung cancer treatments in 1 National Cancer Institute Cooperative Group, only a minority have usable data concerning smoking‐related variables. Clinical trials research is needed to inform patients with cancer and their physicians about the impact of smoking, and how smoking cessation may affect the course of their disease.

Research Priorities, Measures, and Recommendations for Assessment of Tobacco Use in Clinical Cancer Research

There is strong evidence that cigarette smoking causes adverse outcomes in people with cancer. However, more research is needed regarding those effects and the effects of alternative tobacco products and of secondhand smoke, the effects of cessation (before diagnosis, during treatment, or during survivorship), the biologic mechanisms, and optimal strategies for tobacco dependence treatment in oncology. Fundamentally, tobacco is an important source of variation in clinical treatment trials. Nevertheless, tobacco use assessment has not been uniform in clinical trials. Progress has been impeded by a lack of consensus regarding tobacco use assessment suitable for cancer patients. The NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified priority research areas and developed recommendations for assessment items and timing of assessment in cancer research. A cognitive interview study was conducted with 30 cancer patients at the NIH Clinical Center to evaluate and improve the measurement items. The resulting Cancer Patient Tobacco Use Questionnaire (C-TUQ) includes "Core" items for minimal assessment of tobacco use at initial and follow-up time points, and an "Extension" set. Domains include the following: cigarette and other tobacco use status, intensity, and past use; use relative to cancer diagnosis and treatment; cessation approaches and history; and secondhand smoke exposure. The Task Force recommends that assessment occur at study entry and, at a minimum, at the end of protocol therapy in clinical trials. Broad adoption of the recommended measures and timing protocol, and pursuit of the recommended research priorities, will help us to achieve a clearer understanding of the significance of tobacco use and cessation for cancer patients.

Cognitive testing of tobacco use items for administration to patients with cancer and cancer survivors in clinical research

BACKGROUND

To the authors' knowledge, there are currently no standardized measures of tobacco use and secondhand smoke exposure in patients diagnosed with cancer, and this gap hinders the conduct of studies examining the impact of tobacco on cancer treatment outcomes. The objective of the current study was to evaluate and refine questionnaire items proposed by an expert task force to assess tobacco use.

METHODS

Trained interviewers conducted cognitive testing with cancer patients aged ≥21 years with a history of tobacco use and a cancer diagnosis of any stage and organ site who were recruited at the National Institutes of Health Clinical Center in Bethesda, Maryland. Iterative rounds of testing and item modification were conducted to identify and resolve cognitive issues (comprehension, memory retrieval, decision/judgment, and response mapping) and instrument navigation issues until no items warranted further significant modification.

RESULTS

Thirty participants (6 current cigarette smokers, 1 current cigar smoker, and 23 former cigarette smokers) were enrolled from September 2014 to February 2015. The majority of items functioned well. However, qualitative testing identified wording ambiguities related to cancer diagnosis and treatment trajectory, such as "treatment" and "surgery"; difficulties with lifetime recall; errors in estimating quantities; and difficulties with instrument navigation. Revisions to item wording, format, order, response options, and instructions resulted in a questionnaire that demonstrated navigational ease as well as good question comprehension and response accuracy.

CONCLUSIONS

The Cancer Patient Tobacco Use Questionnaire (C-TUQ) can be used as a standardized item set to accelerate the investigation of tobacco use in the cancer setting. Cancer 2016;122:1728-34. © 2016 American Cancer Society.

Exploring Issues of Comorbid Conditions in People Who Smoke

Smoking affects comorbid disease outcomes, and patients with comorbid conditions may have unique characteristics that are important to consider when treating tobacco use. However, addressing tobacco in patients being treated for comorbid conditions is not a consistent practice. Recognizing the need for a "call-to-action" to address tobacco use in people with comorbid conditions, the Tobacco Treatment Network within the Society for Research on Nicotine and Tobacco (SRNT) convened a Comorbidities Workgroup to explore the relationship between smoking and comorbid disease to identify common themes including: the harms associated with continued tobacco use, the frequency of comorbid disease and tobacco use, the potential effect of comorbid disease on the ability to quit tobacco use, the association between tobacco use and suboptimal disease-specific treatment response, and evidence regarding potential approaches to improve addressing tobacco use in patients with comorbid disease. Five candidate conditions (psychiatric, cancer, cardiovascular, pulmonary, and human immunodeficiency virus infected patients) were explored. Across comorbid conditions, smoking adversely affects treatment efficacy and promotes other adverse health conditions. People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Further work is needed to disseminate evidence-based care into clinical practice for smokers with comorbid disease and addiction research should consider comorbid conditions as an important construct to explore.

IMPLICATIONS

This article explores how physical and psychiatric conditions may interact in the treatment of tobacco dependence, and discusses the need for smoking cessation as a critical component of comorbid condition management. Five common comorbid domains-psychiatric, cancer, pulmonary, cardiovascular, and human immunodeficiency virus (HIV)-are highlighted to illustrate how these different conditions might interact with smoking with respect to prevalence and harm, motivation to quit, and cessation treatment utilization and success.

Tobacco and lung cancer: risks, trends, and outcomes in patients with cancer

Tobacco use, primarily associated with cigarette smoking, is the largest preventable cause of cancer mortality, responsible for approximately one-third of all cancer deaths. Approximately 85% of lung cancers result from smoking, with an additional fraction caused by secondhand smoke exposure in nonsmokers. The risk of lung cancer is dose dependent, but can be dramatically reduced with tobacco cessation, especially if the person discontinues smoking early in life. The increase in lung cancer incidence in different countries around in the world parallels changes in cigarette consumption. Lung cancer risks are not reduced by switching to filters or low-tar/low-nicotine cigarettes. In patients with cancer, continued tobacco use after diagnosis is associated with poor therapeutic outcomes including increased treatment-related toxicity, increased risk of second primary cancer, decreased quality of life, and decreased survival. Tobacco cessation in patients with cancer may improve cancer treatment outcomes, but cessation support is often not provided by oncologists. Reducing the health related effects of tobacco requires coordinated efforts to reduce exposure to tobacco, accurately assess tobacco use in clinical settings, and increase access to tobacco cessation support. Lung cancer screening and coordinated international tobacco control efforts offer the promise to dramatically reduce lung cancer mortality in the coming decades.

Interventions for smoking cessation in people diagnosed with lung cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Integration of tobacco cessation services into multidisciplinary lung cancer care: rationale, state of the art, and future directions

Tobacco use is the largest risk factor for lung cancer and many lung cancer patients still smoke at the time of diagnosis. Although clinical practice guidelines recommend that all patients receive evidence-based tobacco treatment, implementation of these services in oncology practices is inconsistent and inadequate. Multidisciplinary lung cancer treatment programs offer an ideal environment to optimally deliver effective smoking cessation services. This article reviews best practice recommendations and current status of tobacco treatment for oncology patients, and provides recommendations to optimize delivery of tobacco treatment in multidisciplinary practice.

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

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

Cigarette smoking, physical activity, and alcohol consumption as predictors of cancer incidence among women at high risk of breast cancer in the NSABP P-1 trial

BACKGROUND

NSABP P-1 provides an opportunity to examine the association of behavioral factors with prospectively monitored cancer incidence and interactions with tamoxifen.

METHODS

From 1992 to 1997, 13,388 women with estimated 5-year breast cancer risk greater than 1.66% or a history of lobular carcinoma in situ (87% younger than age 65; 67% postmenopausal) were randomly assigned to tamoxifen versus placebo. Invasive breast cancer, lung cancer, colon cancer, and endometrial cancer were analyzed with Cox regression. Predictors were baseline cigarette smoking, leisure-time physical activity, alcohol consumption, and established risk factors.

RESULTS

At median 7 years follow-up, we observed 395, 66, 35, and 74 breast cancer, lung cancer, colon cancer, and endometrial cancer, respectively. Women who had smoked were at increased risk of breast cancer (P = 0.007; HR = 1.3 for 15-35 years smoking, HR = 1.6 for ≥ 35 years), lung cancer (P < 0.001; HR = 3.9 for 15-35 years, HR = 18.4 for ≥ 35 years), and colon cancer (P < 0.001; HR = 5.1 for ≥ 35 years) versus never-smokers. Low activity predicted increased breast cancer risk only among women assigned to placebo (P = 0.021 activity main effect, P = 0.013 activity-treatment interaction; HR = 1.4 for the placebo group) and endometrial cancer among all women (P = 0.026, HR = 1.7). Moderate alcohol (>0-1 drink/day) was associated with decreased risk of colon cancer (P = 0.019; HR = 0.35) versus no alcohol. There were no other significant associations between these behaviors and cancer risk.

CONCLUSION

Among women with elevated risk of breast cancer, smoking has an even greater impact on breast cancer risk than observed in past studies in the general population.

IMPACT

Women who smoke or are inactive should be informed of the increased risk of multiple types of cancer.

Second-Hand Smoke As a Predictor of Smoking Cessation Among Lung Cancer Survivors

Purpose

Second-hand smoke (SHS; ie, exposure to smoking of friends and spouses in the household) reduces the likelihood of smoking cessation in noncancer populations. We assessed whether SHS is associated with cessation rates in lung cancer survivors.

Patients and Methods

Patients with lung cancer were recruited from Princess Margaret Cancer Centre, Toronto, ON, Canada. Multivariable logistic regression and Cox proportional hazard models evaluated the association of sociodemographics, clinicopathologic variables, and SHS with either smoking cessation or time to quitting.

Results

In all, 721 patients completed baseline and follow-up questionnaires with a mean follow-up time of 54 months. Of the 242 current smokers at diagnosis, 136 (56%) had quit 1 year after diagnosis. Exposure to smoking at home (adjusted odds ratio [aOR], 6.18; 95% CI, 2.83 to 13.5; P < .001), spousal smoking (aOR, 6.01; 95% CI, 2.63 to 13.8; P < .001), and peer smoking (aOR, 2.49; 95% CI, 1.33 to 4.66; P = .0043) were each associated with decreased rates of cessation. Individuals exposed to smoking in all three settings had the lowest chances of quitting (aOR, 9.57; 95% CI, 2.50 to 36.64; P < .001). Results were similar in time-to-quitting analysis, in which 68% of patients who eventually quit did so within 6 months after cancer diagnosis. Subgroup analysis revealed similar associations across early- and late-stage patients and between sexes.

Conclusion

SHS is an important factor associated with smoking cessation in lung cancer survivors of all stages and should be a key consideration when developing smoking cessation programs for patients with lung cancer.

Automated tobacco assessment and cessation support for cancer patients

BACKGROUND

Tobacco assessment and cessation support are not routinely included in cancer care. An automated tobacco assessment and cessation program was developed to increase the delivery of tobacco cessation support for cancer patients.

METHODS

A structured tobacco assessment was incorporated into the electronic health record at Roswell Park Cancer Institute to identify tobacco use in cancer patients at diagnosis and during follow-up. All patients who reported tobacco use within the past 30 days were automatically referred to a dedicated cessation program that provided cessation counseling. Data were analyzed for referral accuracy and interest in cessation support.

RESULTS

Between October 2010 and December 2012, 11,868 patients were screened for tobacco use, and 2765 were identified as tobacco users and were referred to the cessation service. In referred patients, 1381 of those patients received only a mailed invitation to contact the cessation service, and 1384 received a mailing as well as telephone contact attempts from the cessation service. In the 1126 (81.4%) patients contacted by telephone, 51 (4.5%) reported no tobacco use within the past 30 days, 35 (3.1%) were medically unable to participate, and 30 (2.7%) declined participation. Of the 1381 patients who received only a mailed invitation, 16 (1.2%) contacted the cessation program for assistance. Three questions at initial consult and follow-up generated over 98% of referrals. Tobacco assessment frequency every 4 weeks delayed referral in < 1% of patients.

CONCLUSIONS

An automated electronic health record-based tobacco assessment and cessation referral program can identify substantial numbers of smokers who are receptive to enrollment in a cessation support service.

Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement

When diagnosed with cancer, patients can immediately make a meaningful positive impact on their health by stopping their tobacco use. Scientific evidence clearly shows that tobacco use in patients with cancer leads to poorer outcomes. The specific biological processes driving tobacco consumption's interference in cancer therapy are the subject of continuing research, but the evidence is clear that tobacco use in patients with cancer leads to decreased treatment efficacy and safety, decreased survival, decreased quality of life, increased treatment-related toxicity, and increased risk of cancer recurrence and second primary tumors. Data suggest that tobacco cessation can improve outcomes and survival in patients with cancer, yet full execution of evidence-based cessation interventions is infrequent in oncology settings. Therefore, both improved provision of cessation assistance to all patients with cancer who use tobacco or have recently quit and further study of the deleterious effects of tobacco use and benefits of tobacco cessation on cancer progression and treatment are needed and recommended by the American Association for Cancer Research. Progress on both fronts begins with universal assessment and documentation of tobacco use as a standard of quality cancer care regardless of treatment setting and will be further facilitated through the development of reliable, valid, and standard measures of tobacco use, incorporation of evidence-based procedures into quality and accreditation procedures, and the development of appropriate training, clinical infrastructure, and incentives for delivery of tobacco cessation interventions.

Associations between cigarette smoking status and colon cancer prognosis among participants in North Central Cancer Treatment Group Phase III Trial N0147

PURPOSE

By using data from North Central Cancer Treatment Group Phase III Trial N0147, a randomized adjuvant trial of patients with stage III colon cancer, we assessed the relationship between smoking and cancer outcomes, disease-free survival (DFS), and time to recurrence (TTR), accounting for heterogeneity by patient and tumor characteristics. PATIENTS AND METHODS Before random assignment to infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX) or FOLFOX plus cetuximab, 1,968 participants completed a questionnaire on smoking history and other risk factors. Cox models assessed the association between smoking history and the primary trial outcome of DFS (ie, time to recurrence or death), as well as TTR, adjusting for other clinical and patient factors. The median follow-up was 3.5 years among patients who did not experience events.

RESULTS

Compared with never-smokers, ever smokers experienced significantly shorter DFS (3-year DFS proportion: 70% v 74%; hazard ratio [HR], 1.21; 95% CI, 1.02 to 1.42). This association persisted after multivariate adjustment (HR, 1.23; 95% CI, 1.02 to 1.49). There was significant interaction in this association by BRAF mutation status (P = .03): smoking was associated with shorter DFS in patients with BRAF wild-type (HR, 1.36; 95% CI, 1.11 to 1.66) but not BRAF mutated (HR, 0.80; 95% CI, 0.50 to 1.29) colon cancer. Smoking was more strongly associated with poorer DFS in those with KRAS mutated versus KRAS wild-type colon cancer (HR, 1.50 [95% CI, 1.12 to 2.00] v HR, 1.09 [95% CI, 0.85 to 1.39]), although interaction by KRAS mutation status was not statistically significant (P = .07). Associations were comparable in analyses of TTR.

CONCLUSION

Overall, smoking was significantly associated with shorter DFS and TTR in patients with colon cancer. These adverse relationships were most evident in patients with BRAF wild-type or KRAS mutated colon cancer.

Larynx preservation for patients with locally advanced laryngeal cancer

A 53-year-old man presented with a 6-month history of mild hoarseness, with no associated pain, dysphagia, or stridor. At nasoendoscopy, a lesion was detected involving the whole length of the left vocal cord, with abnormal mucosa also seen in the right ventricle (Fig 1). The left vocal cord movement was impaired. There were no palpable neck nodes. Biopsy under anesthesia revealed moderately differentiated squamous cell carcinoma. He was a current smoker of 30 cigarettes per day (45 pack-year smoking history), and he consumed four standard drinks of alcohol per day. His Eastern Cooperative Oncology Group performance status was 1, and he had no significant comorbidities. Radiologic review of his outside computed tomography scan noted that it was of poor quality, and a magnetic resonance imaging scan was recommended, which showed low-volume T4a disease based on focal thyroid cartilage penetration (Fig 2). A positron emission tomography (PET) scan revealed no evidence of nodal or distant metastasis.