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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: 5
- Now Available
- Moderators:Yuko Nakayama, Michael Menefee
- Coordinates: 9/09/2019, 14:00 - 15:30, Colorado Springs (1994)
ES20.01 - Tobacco Cessation After Cancer Diagnosis: Declaration from IASLC (Now Available) (ID 3267)
14:00 - 15:30 | Presenting Author(s): Jacek Jassem
Tobacco Cessation After Cancer Diagnosis: Declaration from IASLC
Tobacco use is a well established cause of cancer, contributing to about 1 in 3 cancer deaths annually. Whereas detrimental effects of smoking are well recognized, the harms of continued smoking after a cancer diagnosis are undervalued (1). Smoking by cancer patients and survivors causes adverse treatment outcomes, including increased overall mortality, cancer related mortality and risk for second primary cancer, and considerably increases cancer treatment toxicity (2,3). The clinical effects of smoking after a cancer diagnosis has a substantial effect on increased cancer treatment costs (4). Smoking cessation after a cancer diagnosis can improve cancer treatment outcomes (1), but most cancer patients who smoke at the time of diagnosis persist in a smoking habit during long term follow-up (5). Unfortunately, oncologists often do not work with their patients to quit, and do not provide tobacco cessation assistance for continuing tobacco users (6,7). Large analyses of IASLC members demonstrate that although most oncologists recognize that smoking causes adverse outcomes, approximately 90% ask about tobacco use and 80% advise patients to quit, only few offer assistance with quitting (8). There is a clear and unmet need to address tobacco use in patients with cancer. The diagnosis of cancer is “the teachable moment”, allowing health care professionals the best opportunity to discuss with patients their lifestyle habits, including nicotine addiction (9). An enhanced focus on smoking cessation at the time of a cancer diagnosis and its active promotion may increase patients’ motivation to quit. All patients should be screened for tobacco use and advised on the benefits of tobacco cessation. In patients who continue smoking after diagnosis of cancer evidence-based tobacco cessation assistance should be routinely and integrally incorporated into multidisciplinary cancer care. Smoking status should be a required data element for all prospective clinical studies, and clinical trials of patients with cancer should be designed to determine the most effective tobacco cessation interventions (10). Recognizing the critical importance of smoking cessation to increase the efficacy of cancer treatment, these postulates will be a subject of IASLC Declaration presented at the 20th World Conference On Lung Cancer in Barcelona.
1. Warren GW, Simmons VN. Tobacco Use and the Cancer Patient. In: Lawrence TL. editor. DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology, 11th ed. Philadelphia, PA: Lippincott, Williams, & Wilkins, 2018.
2. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, 2014.
3. Jassem J. Tobacco smoking after diagnosis of cancer: clinical aspects. Transl Lung Cancer Res 2019. doi: 10.21037/tlcr.2019.04.01
4. Warren GW, Cartmell KB, Garrett-Mayer E, et al. Attributable failure of first-line cancer treatment and incremental costs associated with smoking by patients with cancer. JAMA Netw Open 2019;2:e191703.
5. Westmaas JL, Newton CC, Stevens VL, et al. Does a recent cancer diagnosis predict smoking cessation? An analysis from a large prospective US cohort. J Clin Oncol. 2015;33:1647-52.
6. Burke L, Miller LA, Saad A, et al. Smoking behaviors among cancer survivors: an observational clinical study. J Oncol Pract 2009; 5: 6-9.
7. Warren GW, Marshall JR, Cummings KM, et al. Addressing tobacco use in patients with cancer: a survey of American Society of Clinical Oncology members. J Oncol Pract 2013; 9: 258-62.
8. Warren GW, Marshall JR, Cummings KM, et al. Practice patterns and perceptions of thoracic oncology providers on tobacco use and cessation in cancer patients. J Thorac Oncol. 2013;8:543-8.
9. Gritz ER, Fingeret MC, Vidrine DJ et al. Successes and failures of the teachable moment: smoking cessation in cancer patients. Cancer. 2006 Jan 1;106:17-27.
10. Toll BA, Brandon TH, Gritz ER, et al. Assessing tobacco use by cancer patients and facilitating cessation: An American Association for Cancer Research Policy Statement. Clin Cancer Res 2013; 19: 1941-8.
ES20.02 - Why It Matters for Patients to Quit - What We’ve Done (Now Available) (ID 3263)
14:00 - 15:30 | Presenting Author(s): Abhishek Shankar
Smoking after a cancer diagnosis causes adverse outcomes including increasing overall mortality, cancer specific mortality, and risk for second primary cancer. Continued smoking is also associated with increased toxicity from cancer treatment. The best method to prevent the adverse effects of smoking is to assist patients with quitting. However, large surveys consistently demonstrate that while most providers ask about tobacco use and advise patients to quit, most oncologists unfortunately do not provide assistance. Predictive barriers to providing assistance with quitting include a lack of time, education, and resources. Continued smoking after a diagnosis can result in substantial added cancer treatment costs, which can be used to justify resources to assist patients with quitting. Methods to assist patients include counseling and pharmacotherapy. Considering in person or phone based approaches to cessation support is important to implement effective and sustainable changes within each practice setting. As approaches are implemented, significant opportunity exists to increase the efficiency of smoking cessation in cancer care. Additional opportunities exist for identifying optimal cancer treatment strategies for cancer patients who smoke. The key to realizing the clinical and financial benefits of addressing tobacco use in cancer care is the systemic incorporation of standardized approaches to identifying tobacco use, providing assistance for patients to quit, and tracking tobacco use after diagnosis in combination with monitoring clinical outcomes.”
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.
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
ES20.04 - Tobacco Control Integration in Cancer Care: The Jordan Experience (Now Available) (ID 3265)
14:00 - 15:30 | Presenting Author(s): Feras Ibrahim Hawari
Tobacco Control Integration in Cancer Care: The Jordan Experience
Tobacco control is an integral component of any action plan that aims to reduce cancer incidence and mortality. Efforts at King Hussein Cancer Center, the only comprehensive cancer center in Jordan and the region, started 10 years ago. We sought to address the tobacco epidemic in Jordan on multiple fronts. In Jordan, tobacco prevalence exceeds 60%. About 50% of patients presenting with a cancer diagnosis are smokers. Integrating tobacco control in general and tobacco dependence treatment in patients suffering from cancer is pivotal. Smoking in patients with cancer has been shown to impact cancer treatment, increase complications from cancer treatment, increase cancer recurrence, increase the odds of development of secondary malignancies and eventually decrease overall long-term survival. Throughout the last 10 years our tobacco dependence tretament program grew in services and scope. The program addressed three major components required for tobacco control in cancer patients: First, patient-centered clinical tobacco dependence treatment service. Second, tobacco dependence treatment training and education for health-care providers. Third, research that addresses tobacco dependence in cancer patients. Our program provides 6 smoking cessation clinics every week dedicated mainly to our cancer patients. We have managed to address training needs for our staff by establishing a tobacco treatment specialist training program, the first ever to be accredited by The Council for Tobacco Treatment Training Programs outside the USA. We studied outcomes of our treatment program and developed means to improve referral to smoking cessation clinics as well as improve the abstinence of our patients. In addition, we studied knowledge, attitude and perception of our health care providers working at our institution; a step especially important in a country where significant numbers of health care providers are smokers. Finally, we studied the impact of our tobacco dependence treatment program on the survival of our patients. Understanding the impact of smoking cessation on short-term survival of patients with cancer (2 years) highlights the importance of integrating such programs as part of the acute treatment phase of these patients. Cancer registry and smoking cessation clinic data for cancer patients diagnosed between 2012 and 2016 were analyzed. Approximately 19% of cancer patients were seen at the smoking cessation clinic. In a sub-sample of 2,387 patients, a significant two-year survival advantage was observed for smokers who had visited the smoking cessation clinic and confirmed that they had not smoked on at least two of their 3, 6 or 12-month follow-up visits (HR 2.8, 95% confidence interval [CI] = 1.7–4.5) relative to those who never went to the smoking cessation clinic. Those at the smoking cessation clinic who were abstinent at only one follow-up point also exhibited a survival advantage (non-abstainers at the smoking cessation had comparable survival to those who were not seen at the clinic).
In conclusion, tobacco control in patients with cancer has an important role in the outcome and survival of these patients and must be integrated in their short and long-term plan of care.
ES20.05 - Tobacco Control in Indonesia (Now Available) (ID 3266)
14:00 - 15:30 | Presenting Author(s): Sita Andarini
Tobacco Control in Indonesia
Indonesia is the largest archipelago country of more than 17,000 islands over 5,200 km width, with population over 260 million makes it fourth most populated country in the world. As the largest economy in South East Asia, and member of G20 country, Indonesia’s economy growth is second fastest growing economy after China. A changing in socioeconomic profile of Indonesia is in paralel with increase prevalence of tobacco smoking. Current data showed prevalence of current adult male tobacco smoking is 64.9% which predicted to increase to 79% in the year of 2030, while youth male prevalence of current tobacco use is 23.0% and current cigarette smoking is 21.4%. This number is highest for daily smoking rate in male, and two third Indonesian women are regularly exposed to second-hand tobacco smoke.
Indonesia’s life expectancy increased between 1990 and 2016 at 8 years to 71.7 years (7.4 years for male and 8.7 years for female). Double health burden due to mix of communicable and noncommunicable diseases. Of all proportional mortality, 35% are cardiovascular diseases, 12% cancer, 6% chronic respiratory diseases, 21% communicable, maternal, perinatal and nutritional conditions, 6% injuries, 6% diabetes. Noncommunicable disease are estimated to responsible for 73% of all death in Indonesia. The increasing leading causes of DALYs in 2017 as compared to 1990 are ischaemic heart disease, cerebrovascular diseases, diabetes, COPD, lung cancer. Tobacco listed as fourth risk factor of cause of death after high systolic blood pressure, dietary risks, high fasting plasma glucose.
Tobacco control remains contradictionary within the country, despite strong national tobacco control program and government law implementation, Indonesia has yet to sign the WHO Framework Convention on Tobacco Control.
National tobacco control program in Indonesia were transformed into specific national government objectives in tobacco control, such as national agency of technical unit for tobacco control, through MPOWER activities. Monitor tobacco use and prevention policies were implemented in Indonesian Law Article 26/2009 for Health and translated in Goverment Ordinant Article 109/2012 for the Security and Restriction of Addictive Substance of Tobacco and other several Presidential Decrees and Ministerial Decrees. Protect people from tobacco smoke were implemented in Ministerial Decree, and Provincional Decree for for Tobacco Smoke Free policy. Offer help to quit tobacco use were included in Ministerial of Health Decree and implemented in National Smoking Cessation Program. Warn about the dangers of tobacco were translated in Ministrerial Decrees Article 56/2017 for tobacco health effect warning in tobacco products and pictorial warning of tobacco smoke. Enforce bans on tobacco advertising, promotion and sponsorship were implemented through Indonesian Broadcasting Law Article 46 Clause 3B prohibits promotion of addictive substances, and Raise taxes on tobacco were implemented in Ministry of Finance Decree article 222/2017 regarding using, monitoring and evaluation of tobacco tax income. Moreover, Presidential Decree article 44/2016 and Ministry of Industry Decree Article 64/2014 for Regulation and Control of tobacco industry.
Tobacco and related indutries argued against tobacco control policy by mentioning largescale effects of tobacco industry for Indonesian economy, and controlling tobacco industry will create massive unemployment, and economic crisis. Ministry of Industry of Republic Indonesia mentioned that tobacco industry creates 5.98 million employments, in which 4.28 million in manufacture and distribution, and 1.7 million people working in tobacco farming. In 2018, export rate of tobacco as cigarettes and cigar were 931.6 million USD, increasing 2.98% as compared to 2017. Tobacco company links closely to small medium enterprises as the tobacco company’s social responsibility (CSR) program. One CSR program as retail community, was founded in 34 provinces, 408 cities which included 60,000 small business retail. Other tobacco related industry's CSR are including sports, youth and creative activities nationwide.
Since 1968, Indonesia National Health insurance system was only implemented for formal sector, individual, civil servants, police and military member, but, since 2014, Indonesian Government launched Universal Health System called Jaminan Kesehatan Nasional (JKN) for all Indonesian. In 2017 approximately 180.7 million people are insured through JKN, 70% of total population and planned to reach 95% target in 2019. While tobacco industry tax income were IDR 153 trillion (approximately USD 10.9 billion) in the year of 2018, tobacco related lost due to early death and disease were IDR 4,200 trillion (one third of national GDP), and economy related lost due to tobacco consumption were approximately IDR 596 trillion. This should be bear in mind, that amount of tax income from tobacco company is incomparable to high burden loss due to tobacco related morbidity and mortality.
Mboi N, Surbakti IM, Trihandini I, Elyazar I, Smith KH, Ali PB et al. On the road to universal health care in Indonesia, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2018;392:581-91.
Xi B, Liang Y, Liu Y, Yan Y, Zhao M, Ma C, Bovet P. Tobacco use and second-hand smoke exposure in young adolescents aged 12-15 years: data from 68 low-income and middle-income countries. Lancet Glob Health 2016:4:e795-805.
World Health Organization – Noncommunicable Diseases (NCD) Country Profiles, 2018.
Cited from Indonesian Ministry of Industry press release. http://www.kemenperin.go.id/artikel/17257/Kontribusi-Besar-Industri-Hasil-Tembakau-Bagi-Ekonomi-Nasional
Agustina R, Dartanto T, Sitompul R, Susiloretni KA, Suparmi, Achadi EL et al. Universal health coverage in Indonesia: concept, progress, and challenges. Lancet 2019;393(10166):75-102.