Urologist-led smoking cessation: a way forward through implementation science

Association between smoking and prostate cancer survivors' long-term quality of life and function: an analysis of the CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study

PURPOSE

There is limited evidence of tobacco smoking's effect on cancer survivors' quality of life (QOL) and function. As the natural history of localized prostate cancer (PCa) is protracted, there is a need to identify modifiable risk factors that can influence PCa survivorship, such as tobacco smoking.

MATERIAL AND METHODS

We used up to 10-year survey data from the CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study, a prospective, population-based, observational study of patients diagnosed with localized PCa in 2011-2012. Survivors were categorized as never, former, and current smokers during survivorship. Adjusted multivariable linear regression models were used to assess the association between smoking and 5-year and 10-year scores on the 26-Item Expanded Prostate Index Composite (EPIC-26; PCa-specific domains) and 5-year scores on the Medical Outcomes Study 36-Item Short Form Survey (SF-36; general health domains).

RESULTS

We included 2426 patients of whom 142 (6%) were current smokers, 1039 (43%) were former smokers, and 1245 (51%) were never smokers. Current smokers were more likely to be Black, low-income, and less formally educated (all p < 0.01). After adjustments, there was no association between smoking history with disease-specific functional outcomes (EPIC-26) at 5 years or 10 years (all p > 0.05). However, in adjusted analyses assessing general health domains (SF-36), compared to participants who never smoked, current smokers during survivorship had worse physical function (- 10.96, 95% CI - 16.37 to - 5.55, p < 0.01) at 5 years.

CONCLUSION

PCa survivors who continue to smoke experience worse physical functioning though there is no significant independent effect on PCa-specific functional domains.

IMPLICATIONS FOR CANCER SURVIVORS

Prostate cancer survivors who continue to smoke experience worse physical functioning though there is no significant independent effect on PCa-specific functional domains. Smoking cessation may improve prostate cancer survivorship.

Urologist's role on smoking cessation counseling in patients presenting with asymptomatic hematuria: single academic institution experience

Background

Bladder cancer is known to be strongly associated with smoking tobacco products. Urologists thus have an imperative role in providing smoking cessation counseling to patients to prevent the development of bladder cancer, recurrence, and other morbidities associated with smoking. Asymptomatic hematuria is often a presenting clinical symptom that warrants further investigation. This study aims to determine if smokers who have an episode of asymptomatic hematuria are more likely to quit smoking if urologists counsel them on formal smoking cessation.

Methods

We completed a retrospective chart review of patients who presented for asymptomatic hematuria at our institution between January 2017 and March 2020. A total of 435 patients were identified, 134 of which were active smokers at the presentation time. We recorded smoking status at initial presentation, documentation of smoking cessation counseling, and smoking status at one year follow-up. Fischer's exact test was used for analysis. Statistical significance was set by convention at P<0.05.

Results

The percentage of patients presenting with an episode of asymptomatic hematuria that quit or cut back at one year follow-up was 24.2% [95% confidence interval (CI): 13.8%, 34.7%]. In assessing the effect of formal smoking cessation counseling, 33.3% of patients with documented smoking cessation counseling quit or cut back at one year, compared to 22.8% of patients with no documented counseling. However, these findings were not statistically significant (P=0.68). Of note, smoking cessation counseling was recorded in 19 active smokers (14.2%), and 68 active smokers (50.7%) did not receive follow-up at one year.

Conclusions

Smoking cessation remains a challenging endeavor for both patients and urologists. Formal counseling did not significantly contribute to quitting rates among patients, and rates of documented counseling from providers were unsubstantial. Urologists should use hematuria work-up visits as an opportunity to counsel patients on smoking cessation.

Bladder Cancer Survivors Who Do Not Smoke Have Better Longitudinal Health-Related Quality of Life Measures: An Assessment of the Comparative Effectiveness and Survivorship Health in Bladder Cancer (CEASE-BC) Study

PURPOSE

Cigarette smoking is the most common risk factor for the development of bladder cancer (BC), yet there is a paucity of data characterizing the relationship between smoking status and longitudinal health-related quality of life (HRQoL) outcomes in patients with BC. We examined the association between smoking status and HRQoL among patients with BC.

MATERIALS AND METHODS

Data were sourced from a prospective, longitudinal study open between 2014 and 2017, which examined HRQoL in patients aged ≥ 18 years old diagnosed with BC across North Carolina. The QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire core instrument) was administered at 3, 12, and 24 months after BC diagnosis. Our primary exposure of interest was current smoking status. Linear regression using generalized estimating equations was used to analyze the relationship between smoking status and various domains of the QLQ-C30.

RESULTS

A total of 154 patients enrolled in the study. Eighteen percent were classified as smoking at 3 months from diagnosis, and packs per day ranged from < 0.5 to 2. When controlling for time from diagnosis, demographic covariates, cancer stage, and treatment type, mean differences for physical function (7.4), emotional function (5.6), and fatigue measures (-8.2) were significantly better for patients with BC who did not smoke.

CONCLUSIONS

Patients with BC who do not smoke have significantly better HRQoL scores in the domains of physical function, emotional function, and fatigue. These results underscore the need to treat smoking as an essential component of BC care.

Patterns of Smoking Cessation Strategies and Perception of E-cigarette Harm Among Bladder Cancer Survivors

BACKGROUND

Cigarette smoking is the leading preventable cause of bladder cancer (BC). Some proponents of e-cigarettes describe their use as a risk mitigation strategy despite potential carcinogen exposure and uncertain long-term risks.

OBJECTIVE

We assessed smoking cessation strategies, including e-cigarette use, and harm perception among patients with BC.

METHODS

We performed a cross-sectional study on a convenience sample of patients with BC at a single institution from August 2021 - October 2022. The survey instrument was sourced from the Cancer Patient Tobacco Use Questionnaire (C-TUQ) from the American Association for Cancer Research with standardized questions on tobacco use, cessation questions, and e-cigarette harm perceptions.

RESULTS

Of the 104 surveyed BC patients (mean age: 72 years; 27% female; 55% with muscle-invasive disease), 20% were current smokers (median pack years: 40) and 51% were former smokers (median pack years: 20). A minority (9%) had quit smoking at the time of diagnosis. Pharmacotherapy for smoking cessation included nicotine patches (25%), gum (21%), lozenges (8%), e-cigarettes (8%), and Varenicline/Bupropion (4%). Notably, 43% of patients who continued to smoke expressed willingness to switch to e-cigarettes as a cessation aid. E-cigarette users (11%) more commonly perceived e-cigarettes as non-harmful compared to former (4%) and non-smokers (4%) (P = .048), though all groups regarded e-cigarettes as equally addictive as traditional cigarettes.

CONCLUSIONS

Despite the prevalence of BC survivors who continue to smoke, a significant proportion perceive e-cigarettes as a viable and less harmful cessation aid. The infrequent use of FDA-approved pharmacotherapies underscores potential implementation gaps. These findings highlight the need for further research and targeted interventions in addressing smoking cessation among BC survivors.

Smoking cessation pharmacotherapy use during index hospital admission following cystectomy for bladder cancer: A retrospective cohort study

BACKGROUND

To identify gaps in urologic oncology quality and evidence-based smoking cessation care by assessing how often smoking cessation pharmacotherapy (SCP) is given in the inpatient setting following cystectomy.

METHODS

The Premier Healthcare Database (PHD), a deidentified all-payer dataset, was used to generate nationally representative estimates of SCP receipt during hospitalization following cystectomy for patients with bladder cancer who smoke. Regressions were used to model associations between SCP receipt and patient- and hospital-level factors.

RESULTS

Of the 21,624 patients who underwent cystectomy for bladder cancer, 3,676 patients (17.0%) were identified as current smokers, representing a weighted estimate of 16,063 admissions. Among these admissions, 27.9% of patients received SCP, the vast majority of which (91.5%) received exclusively nicotine replacement therapy. Rates of SCP receipt varied substantially across hospitals (median: 25.0%, IQR: 20.0-33.3, range: 0.0-60.0). Older age and black race (aOR = 0.59, 95% CI: 0.42-0.82) were associated with lower odds of SCP receipt. Increased patient comorbidity score was associated with higher odds of SCP receipt (aOR = 1.02, 95% CI: 1.01-1.03); specifically, chronic pulmonary disease, alcohol abuse, and depression were independently associated with SCP receipt. Hospital teaching status, bed capacity, and mean annual cystectomy volume were not associated with SCP receipt. SCP receipt was not associated with hospital length of stay nor 90-day readmission or mortality following cystectomy.

CONCLUSIONS

SCP is infrequently given to patients who smoke during their hospitalization following cystectomy for bladder cancer, representing a gap in quality urologic oncology care and a missed opportunity to effectively intervene with evidence-based treatment.

Prostate cancer mortality in Brazil 1990-2019: geographical distribution and trends

INTRODUCTION:

To analyze the trend of prostate cancer mortality in the Brazilian population of 40 years of age and above.

METHODS:

Time series ecological study of the mortality rates due to prostate cancer in men of 40 years of age and above, using data from the Global Burden of Disease 2019 (GBD). Age-standardized mortality rates were calculated, as well as the age-standardized rates by the GBD for the global population, per 100,000 inhabitants, for Brazil and its States, from 1990 to 2019. The annual average percent change (AAPC) was calculated to identify the mortality trends in Brazil, through linear regression using the Joinpoint Regression Program.

RESULTS:

The standardized rates of prostate cancer mortality in Brazil were 76.89 in 1990 and 74.96 deaths for every 100 thousand men ≥ 40 years of age in 2019, with a stability trend. By age group, it was observed a decreasing trend up to 79 years of age, and an increasing trend as of 80 years of age. The state of Bahia showed the highest increase in mortality in the period (1.2%/year), followed by Maranhão and Pernambuco (1.0 and 0.9%/year). A decrease of prostate cancer mortality was found in the Federal District, Goiás, Minas Gerais, Rio de Janeiro, Rio Grande do Sul, Roraima, Santa Catarina, São Paulo, and Sergipe.

CONCLUSIONS:

In Brazil, the standardized mortality rates show a trend toward stability from 1990 to 2019 and no pattern was observed for the trends according to the Brazilian States.

Using a multilevel implementation strategy to facilitate the screening and treatment of tobacco use in the outpatient urology clinic: A prospective hybrid type I study

BACKGROUND

Urologists frequently treat patients for tobacco-related conditions but infrequently engage in evidence-based practices (EBPs) that screen for and treat tobacco use. Improving the use of EBPs will help to identify smokers, promote cessation, and improve patients' health outcomes.

METHODS

A prospective type I hybrid effectiveness-implementation study was performed to test the feasibility and effectiveness of using a multilevel implementation strategy to improve the use of tobacco EBPs. All urology providers at outpatient urology clinics within the Veterans Health Administration Greater Los Angeles and all patients presenting for a new urology consultation were included. The primary outcome was whether a patient was screened for tobacco use at the time of consultation. Secondary outcomes included a patient's willingness to quit, chosen quit strategy, and subsequent engagement in quit attempts.

RESULTS

In total, 5706 consecutive veterans were seen for a new consultation during the 30-month study period. Thirty-six percent of all visits were for a tobacco-related urologic diagnosis. The percentage of visits that included tobacco use screening increased from 18% (before implementation) to 57% in the implementation phase and to 60% during the maintenance phase. There was significant provider-level variation in adherence to screening. Of all screened patients, 38% were willing to quit, and most patients chose a "cold turkey" method; 22% of the patients elected referral to a formal smoking cessation clinic, and 24% chose telephone counseling. Among those willing to quit, 39% and 49% made a formal quit attempt by 3 and 6 months, respectively.

CONCLUSIONS

A strategy that includes provider education and a customized clinical decision support tool can facilitate provider use of tobacco EBPs in a surgery subspecialty clinic.

Fighting the 'tobacco epidemic' - A call to action to identify Targeted Intervention Points (TIPs) for better counseling patients with urothelial cancer

The association between tobacco use and urothelial cancer of the bladder is well known. Given the worsening tobacco epidemic, here we make the case for systematic targeted points of intervention for urologists and other professionals to intervene against bladder cancer. Awareness of contemporary checkpoints where we can intervene for counseling patients may help medical education in a tobacco-pandemic difficult setting.

Association of smoking status and recurrence of non-muscle invasive bladder cancer among patients managed with blue light cystoscopy

PURPOSE

Smoking has a strong causal association with bladder cancer but the relationship with recurrence is not well established. We sought to assess the association of smoking status on recurrence of non-muscle invasive bladder cancer (NMIBC) in a contemporary cohort of patients with predominantly high-risk, recurrent NMIBC managed with photodynamic enhanced cystoscopy.

MATERIALS AND METHODS

We performed a retrospective study of patients with NMIBC included in a multi-institutional registry. Our primary exposure of interest was smoking status. Our primary outcome was first recurrence of NMIBC. Kaplan-Meier analysis was used to calculate recurrence free probabilities and Cox proportional hazards regression was used to evaluate the impact of smoking status on recurrence free survival.

RESULTS

Our analytic cohort included 723 adults with bladder cancer, 11.5% with primary NMIBC and 88.5% with recurrent NMIBC. The majority of patients were white, male, and had high-risk NMIBC (72.6%). 52.6% of included patients were former smokers and 12.7% were current smokers. During the three-year study period, there was a NMIBC recurrence in 259 of the 723 patients (35.8%). The 1- and 3-year probability of recurrence was 19% and 44%, respectively. The grade and stage of recurrences were 28.9% LG Ta, 34.4% HG Ta, 15.8% pure CIS, 0.3% LG T1, 15.4% HG T1, and 5.4% unknown. After adjustment for a priori clinical and demographic factors, smoking status had no significant association with recurrence.

CONCLUSION

Smoking status was not significantly association with recurrence in a study of patients with predominantly high-risk recurrent NMIBC managed with photodynamic enhanced cystoscopy.

Moving urologic disparities research from evidence synthesis to translational research: a dynamic, multidisciplinary approach to tackling inequalities in urology

Disparities in urology are well-documented but less is known about the role of translational research within existing interventional models to address inequalities. In this narrative review, we utilize an accepted framework of the process of translational research in mitigating disparities to investigate current translational and interventional urologic programs that bridge the gap. Three established, disparity-focused urologic interventional programs were identified and are highlighted in depth. Finally, we extrapolate from these findings to provide 10 policy relevant implications to help move urologic disparities research from evidence synthesis to translational research.