Helping Cancer Patients Quit Smoking Through Counseling and Pharmacotherapy
At the 22nd Annual Conference of the National Comprehensive Cancer Network (NCCN), in Orlando, Florida, Paul M. Cinciripini, PhD, of the University of Texas MD Anderson Cancer Center, delivered a presentation on a mission he said he has spent the better part of his life working on: getting patients with cancer to quit smoking cigarettes.
Cinciripini, who serves as professor and chair for the department of behavioral science as well as director of the Tobacco Treatment Program at the Cancer Center, acknowledged that the audience of mainly oncologists did not need to be convinced that smoking is harmful. He discussed data which indicate over 480,000 deaths per year in the United States are attributable to cigarette smoking, and also summarized the beneficial effects of cessation, including reduced depression, anxiety, and stress, along with improved positive mood and qualityof life (QOL).
These outcomes, both the dangers of smoking and the benefits of cessation, are magnified in cancer patients, Cinciripini explained. Smoking during cancer treatment is associated with an increased risk of recurrence, greater symptom burden, and reduced survival. Response to radiotherapy is diminished in smokers, and they have an increased risk of pulmonary embolism, infection, and poor wound healing. Smokers also experience worsened toxicities and immune impairment while undergoing chemotherapy, although the efficacy of the treatment is diminished.
In one study, patients who quit smoking had a 78% overall survival rate 2 years after radiotherapy, compared with 69% among those who continued to smoke. From a QOL perspective, cancer patients who quit smoking report easier breathing and a boost in energy. Clearly, Cinciripini said, there is a “need for intervention” among this population.
The most effective interventions, he explained, involve a combination of counseling and medications. Recommended first-line medications include varenicline, bupropion, and nicotine-replacement therapies like patches or gum.
Cinciripini cited a large study called the EAGLES trial that found varenicline to be more effective than bupropion, nicotine patch, or placebo in patients with and without psychiatric disorders. The occurrence of severe neuropsychiatric events during treatment, including suicide, was similar across all the tested therapies. Cinciripini nonetheless advised clinicians to think about the patient’s psychiatric background and history when prescribing these treatments, and to “be on the lookout for any untoward changes in their psychiatric profile.”
He then highlighted several studies demonstrating better cessation rates associated with higher intensity counseling, defined as more than 4 sessions lasting 30 to 300 minutes, compared with minimal intensity counseling. Although this more intense treatment costs more, Cinciripini explained that its increased effectiveness makes it more cost effective. He also cited research that found a combination of intense counseling plus the introduction of nicotine replacement therapy before quitting was more effective at 16 and 26 weeks than either intervention alone.
After presenting this literature, Cinciripini discussed the NCCN clinical guidelines for smoking cessation in oncology. First, clinicians must assess patients’ nicotine dependency, history of quit attempts, and readiness to quit. If a patient is ready to quit, the clinician should involve him or her in establishing a plan and setting a quit date. If he or she is not ready, the clinician can help address concerns and suggest pharmacotherapy to reduce the number of cigarettes smoked per day. The goal of this reduction is eventually quitting, Cinciripini emphasized, not just harm reduction.
The primary recommended therapies are a combination of behavioral therapy and either nicotine replacement therapies or varenicline. If a patient succeeds in quitting, the guidelines recommend “motivational strategies for continued abstinence.” If a patient relapses, clinicians can switch the type of therapy, but must be sure to maintain consistent engagement with the patient.
Smoking cessation is “not a one and done” event, Cinciripini emphasized, and requires consistent contact and follow-up by the clinician. “If they quit, great, stay engaged. If they don’t, great, stay engaged,” he summarized.
When the audience was invited to ask questions, an attendee asked Cinciripini his opinion on e-cigarettes as a form of risk mitigation, though he’d previously said he was focusing on complete cessation, not harm reduction.
“I knew I was going to get that question,” Cinciripini sighed jokingly. “The answer is it depends.”
While there isn’t enough data to establish effectiveness and long-term safety for the devices, he said, the reduction in carcinogens makes it preferable to cigarettes and can provide an opening for patients to transition towards eliminating nicotine. Cinciripini said he would not rule out e-cigarettes as a potential tool if researchers had more data, but reiterated he was “most comfortable talking about valid nicotine therapies” as a means for cessation.