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Rebecca Truscott
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ES20 - Strategies for Cancer Patients to Have Optimal Outcomes (ID 23)
- Event: WCLC 2019
- Type: Educational Session
- Track: Prevention and Tobacco Control
- Presentations: 1
- Now Available
- Moderators:Yuko Nakayama, Michael Menefee
- Coordinates: 9/09/2019, 14:00 - 15:30, Colorado Springs (1994)
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ES20.03 - Tobacco Control Integration in Cancer Care: The Canadian Experience (Now Available) (ID 3264)
14:00 - 15:30 | Author(s): Rebecca Truscott
- Abstract
- Presentation
Abstract
The evidence that smoking cessation improves outcomes for cancer patients is irrefutable. Continued smoking after a diagnosis of cancer can increase all-cause and cancer-specific mortality, result in increased adverse treatment effects and cause a higher incidence of recurrence and second malignancies (1,2).
In 2011, Cancer Care Ontario (CCO) noted the potential benefits of smoking cessation in two seminal papers (3,4) and established a Steering Committee to create an implementation framework for a provincial smoking cessation initiative. The framework provided guidance on standard program elements, optional regional initiatives and central administrative support (5). Required elements included screening of all new ambulatory cancer patients using a standardized tobacco screening question to identify current and recent smokers (smoked within past six months); appointment of regional smoking cessation Champions; training for healthcare providers on the health benefits of smoking cessation for cancer patients; referral of patients willing to accept help in quitting; and submission of performance metric data.
Optional elements of the framework were the intensity of the regional smoking cessation intervention and location of smoking cessation services (cancer centre or host hospital vs external provider).
Central administrative support included a secretariat within the division of Prevention and Cancer Control, and a central database within Analytics and Informatics.
Patients were to be screened for smoking status by a nurse or physician using the 5As (ask, advise, assess, assist, arrange) model of smoking cessation. The screening question asked is “Have you used any form of tobacco in the last six months?” To assess a patient’s willingness to quit, the question asked is “Are you interested in learning about what is available to help you avoid smoking/using tobacco in the future?” Centres were to develop an inventory of regional smoking cessation resources. Potential resources included the Canadian Cancer Society’s Smokers’ Helpline – a quit line accessible by phone, web and text-based messages (6), trained pharmacists and family physicians, public health units and hospital and community-based smoking cessation clinics.
In 2016, based on the Ontario initiative, the Canadian Partnership Against Cancer (CPAC) offered funding to all provinces to plan, implement or evaluate smoking cessation initiatives within cancer centres. Seven provinces and two territories made submissions in response to CPAC’s request for proposals, leading to multiple new efforts within cancer agencies across Canada to assist cancer patients to stop smoking (7). Cancer Care Ontario used funding from CPAC to implement educational initiatives for both providers and patients (e.g., development of posters, multilingual brochures and videos), and to conduct a survey to determine best implementation processes. Monthly teleconferences with the regional Champions and annual face-to-face meetings to review progress and celebrate successes were critical success factors.
Other factors that contributed to a successful implementation were strong leadership from the Steering Committee (now Advisory Committee), commitment from CCO executive and clinical leadership and the use of performance metrics and performance management. The initial five key performance metrics were: 1) proportion of ambulatory cancer patients screened for smoking status; 2) proportion of those screened who were current or recent smokers; 3) proportion of smokers advised to quit smoking; 4) proportion of those advised to quit who were recommended a referral to smoking cessation services; and 5) proportion of those offered a referral who accepted a referral. Two metrics (tobacco use screening and accepted a referral) are reviewed on a quarterly basis by senior CCO executives with the regional cancer centre leaders in order to drive change. Targets are set and performance metrics on smoking cessation are used, amongst others, to determine the overall ranking of a cancer centre within the province of Ontario.
Most of the 14 regional cancer centres are achieving the target of 75% of new ambulatory cancer patients screened for tobacco use but fall below the target of 25% for acceptance of a cessation referral. This poor performance led to the adoption of an “opt-out” approach in which patients are automatically referred to smoking cessation services unless they specifically refuse.
It is critical that busy oncologists not be overburdened, and that other frontline staff assume responsibility for implementing the smoking cessation program. “Scripts” can communicate to patients that the physician wants them to stop smoking in order to get the best results from treatment. Using 3As (ask, advise, act) also minimizes the burden on staff.
CPAC has disseminated these learnings across Canada and engaged all 10 provinces and three territories in a 2019-21 funding initiative requiring an evaluation plan with 15 quality indicators. Already, a 10% increase in the level of implementation of evidence-based tobacco cessation programs within ambulatory cancer settings across Canada has occurred (56% adoption in 2017/18; 66% adoption in 2018/19).
The approaches to smoking cessation vary by jurisdiction (7,) but the culture within cancer centres is evolving with a growing realization that it is never too late for a cancer patient to stop smoking, and acceptance that smoking cessation must be integrated into cancer treatment for it to be truly considered quality cancer care.
References:
Toll BA, Brandon TH, Gritz ER et al. AACR subcommittee on tobacco and Cancer. Assessing tobacco use by cancer patients and facilitating cessation: an American Association for Cancer Research policy statement. Cancer Clin Cancer Res 2013; 19:1941 – 1948.
Health consequences of smoking – 50 years of progress: a report of the Surgeon General, 2014. Available at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/
Parson A, Daley A, Begh R, Aveyard P. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ 2010; 340: b5569
Browman GP, Wong G, Hodson I et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med 1993; 328:159 – 76.
Evans WK, Truscott R, Cameron E, et al. Lessons learned implementing a province-wide smoking cessation initiative in Ontario’s cancer centres. Curr Oncol 2017 Jun; (3): 185 – 190.
Get help to quit smoking - Canadian Cancer Society. Available at: https://www.cancer.ca/en/support-and-services/support-services/quit-smoking/?region=on
Integrating Tobacco Cessation + Relapse Prevention to Improve Quality of Cancer Care. Available at: https://content.cancerview.ca/download/cv/prevention_and_screening/tobacco_cessation/documents/integrating_tobacco_cessation_relapse_prevention_one_pager_en_frpdf?attachment=0
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OA09 - Lung Cancer: A Preventable Disease? (ID 134)
- Event: WCLC 2019
- Type: Oral Session
- Track: Prevention and Tobacco Control
- Presentations: 1
- Now Available
- Moderators:Bienvenido Barreiro, Carolyn Dresler
- Coordinates: 9/09/2019, 11:00 - 12:30, Melbourne (1991)
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OA09.07 - Implementing an Opt-Out Approach to Smoking Cessation Referrals for Cancer Patients in Ontario, Canada (Now Available) (ID 2728)
11:00 - 12:30 | Author(s): Rebecca Truscott
- Abstract
- Presentation
Background
Smoking is responsible for approximately 30% of all cancer deaths in Canada and more than 85% of lung cancer cases. Continued smoking results in decreased cancer treatment efficacy and safety, increased toxicities, greater risk of cancer recurrence and second primaries, poorer quality of life and decreased survival. Quitting smoking can reduce these adverse effects. In 2013, Cancer Care Ontario (CCO) implemented a smoking cessation program across 14 Regional Cancer Centres (RCCs) in the province of Ontario, Canada, employing a 3As (Ask, Advise, Act) brief intervention model.
Method
In the first few years of the program, smokers could “opt-in” to smoking cessation services by stating a readiness to quit. However, the provincial rate of smokers accepting support was low. In 2018, CCO adopted an “opt-out” approach, based on emerging evidence and feedback from an expert Advisory Committee. With this approach, healthcare providers (HCPs) automatically refer all smokers to a cessation service, without assessing the patient’s readiness to quit. Patients can refuse the referral if they choose. This program change was communicated to the RCCs through a revised program framework, site-specific action plans, and discussion during monthly knowledge exchange meetings with Regional Champions. Communications resources (posters and pocket cards) were created to support HCPs, with suggested scripts.
Result
The Accepted a Referral (proportion of smokers accepting referral to cessation services) performance metric was used to monitor program implementation. With an opt-in approach, the annual provincial rate of Accepted a Referral improved only slightly over three years (18.1% in 2015/16 to 22.5% in 2017/18). Just prior to launching the opt-out approach in Q3 of 2017/18, the provincial rate of Accepted a Referral was 23.3% (range 9.2% to 37.9% amongst 14 RCCs). One year later, the provincial rate had increased substantially to 31.9% (range 12.9% to 88.7%). Several RCCs showed dramatic increases, while others demonstrated little or no improvement.
Conclusion
In an effort to help more patients quit smoking and to achieve the best treatment outcomes possible, CCO adopted an opt-out approach to cessation referrals. Overall, there has been a substantial increase in the provincial rate of smokers accepting support, but implementation has varied amongst RCCs. Feedback indicates that while some HCPs found the approach relatively easy to implement, others have been resistant to change, expressing concern about the ethics of referring patients without assessing willingness to quit. Further research into the reasons behind the variable uptake of the opt-out approach will inform future implementation efforts.
Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
