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Rachael L Murray

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    S01 - IASLC CT Screening Symposium: Forefront Advances in Lung Cancer Screening (Ticketed Session) (ID 96)

    • Event: WCLC 2019
    • Type: Symposium
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
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      S01.17 - Smoking Cessation (Now Available) (ID 3642)

      07:00 - 12:00  |  Presenting Author(s): Rachael L Murray

      • Abstract
      • Presentation
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      More than 85% of cases of lung cancer are caused by tobacco smoking, and stopping smoking, at any age, significantly reduces lung cancer risk. Despite positive findings reported by the National Lung Screening Trial (NLST) and the Dutch-Belgian Randomised Lung Cancer Screening Trial (NELSON), a number of important questions remain regarding the best way to implement lung cancer screening (LCS), including how most effectively to embed smoking cessation interventions (SCI) into these programmes. One concern that has been raised around LCS for current smokers is the potential ‘moral hazard’ arising from a negative (i.e. reassuring) screening result, which may reduce motivation to quit. Conversely, attendance at a lung cancer screening programme offers a ‘teachable moment’ for smoking cessation, occurring at a time when participating smokers may be particularly receptive to offers of help to quit. Indeed, a negative screen result has been reported as being perceived as a ‘clean slate’ as a motivator to stop smoking.

      Evidence suggests that smoking cessation and low dose computed tomography (LDCT) screening have additive effects on survival; an analysis of participants in the NLST reported a 38% reduction in lung cancer mortality with the combination of smoking abstinence at 15 years with LDCT screening. Further, research has indicated that adding SCIs to LCS improves the cost effectiveness of such programmes. It is, therefore, essential that any lung cancer screening programme provides smoking cessation support for participants.

      Clinical guidelines regarding delivery of smoking cessation interventions in the context of LCS have been produced by the Association for the Treatment of Tobacco Use and Dependence and The Society for Research on Nicotine and Tobacco, but this document acknowledges the paucity of data and need for future research specific to this patient population. Participants in LCS are unlikely to be representative of the general population of smokers, and evidence regarding smoking cessation outcomes in a lung cancer screening (LCS) context is variable.

      There is some evidence to suggest that participation in LCS alone may increase smoking cessation rates above that of the general population, influenced by screening outcomes. However, comparisons between smoking cessation outcomes in screened and control populations in a number of studies have reported inconsistent findings. There is limited proven effectiveness of low intensity SCIs delivered as part of LCS programmes. When comparing such interventions delivered to smokers attending for LCS, there appears to be no difference between standard written advice, internet resources, quitline details or brief advice. However, more intensive interventions such as telephone-based counselling sessions have been shown to be more effective than self-help cessation resources and a combination of cognitive behavioural therapy and pharmacotherapy have shown further promise. Little research exists as to the potential benefits of e-cigarettes for cessation in this setting but given their increasing popularity as a cessation aid this requires further attention. Delivery of a more intensive intervention at the time of screening may be viable; one recent study reported that it was feasible to deliver a single tailored session of motivational interviewing counselling on the day of screening.

      Smoking cessation studies from other settings mayprovide learnings transferrable to the LCS setting. Personalised interventions for smoking cessation are generally more effective than standard approaches. the presence of emphysema and coronary artery calcification may be incidental findings from LDCT scans that could be used as part of an SCI in the LCS setting. This may be particularly pertinent where participants are fit, relatively asymptomatic and hence potentially more susceptible to a message that lung damage had already occurred but clinical impact could be reduced by stopping smoking (as may be the case in LCS attendees).

      Relatively few studies have tested interventions for smoking cessation in LCS settings, and are subject to large variations in timing, setting, participants, SCI and outcome measures which does not allow direct comparison between studies and makes it difficult to draw conclusions regarding optimal interventions. However, it is likely that higher intensity interventions will be more effective and the use of incidental scan findings should be considered. Much research into the best way to integrate SCIs into LCS is now ongoing in an attempt to answer the outstanding implementation questions. The SCALE (Smoking Cessation within the Context of Lung Cancer Screening) collaboration in the US consists of eight clinical trials which seek to build an evidence base for effective interventions in LCS, using a common core of data collection measures to allow pooling of data and comparison across studies. In the UK, the Yorkshire Enhanced Stop Smoking study (YESS) seeks to test the delivery of an intensive SCI, co-located with the Yorkshire Lung Screening Trial (YLST) and personalised to the LCS result. Data from these studies will hopefully add clarity to the question of how best to reduce morbidity and mortality amongst those presenting for LCS.

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