JCO Article Insights: Smoking Cessation for Patients with Cancer
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In this JCO Article Insights episode, Davide Soldato summarizes three articles from the May 20th, 2023 Journal of Clinical Oncology issue: “Smoking Cessation After Diagnosis of Kidney Cancer Is Associated With Reduced Risk of Mortality and Cancer Progression: A Prospective Cohort Study, “Efficacy of a Smoking Cessation Intervention for Survival of Cervical Intraepithelial Neoplasia or Cervical Cancer: A Randomized Control Trial” and “Integrating Tobacco Treatment into Oncology Care: Reach and Effectiveness of Evidence-Based Tobacco Treatment across National Cancer Institute Designated Cancer Centers.” The articles discuss clinical outcomes in survivors of cancers who quit smoking, efficacy of a novel smoking intervention and implementation of tobacco treatment programs.

TRANSCRIPT Davide Soldato: Welcome to this JCO After Hours* issue summary for the May issues of the Journal of Clinical Oncology*. This is Davide Soldato and today I will be reporting results from three articles published in the May issue of JCO*. Today's episode is focused on smoking cessation, impact on clinical outcomes, efficacy of novel smoking interventions, and implementations of tobacco treatment programs.  The first article by Dr. Sheikh and colleagues is titled "Smoking Cessation after Diagnosis of Kidney Cancer is Associated with Reduced Risk of Mortality and Cancer Progression: A Prospective Cohort Study)". We know that smoking is a relevant risk factor for development of renal cell carcinoma, and previous retrospective studies showed better survival among patients who quit smoking after diagnosis. However, prospective data on the topic were lacking up until this point. The study by Dr. Sheikh and colleagues included patients diagnosed with renal cell carcinoma who were current smokers at the moment of diagnosis and that were followed prospectively for an average of eight years. At study inclusion, patients responded to a structured questionnaire investigating smoking habits and other behavioral factors. Furthermore, clinical pathological data were extracted from medical records.  Subsequently, after inclusion, patients provided yearly information regarding smoking status and if applicable, date of smoking cessation. Follow-up information on vital status, eventual disease recurrence, and treatments were collected both from patients and from medical records. The study reports results among 212 patients who were current smokers at diagnosis; the majority were diagnosed with stage I tumors and had a high-level education. Over the eight-year average follow-up, 40% of patients reported quitting smoking, more than half of them shortly after diagnosis. Demographic, social, and tumor characteristics were comparable between patients who quit and those who continued smoking.  Smoking cessation was overall associated with improved outcomes. Five-year survival rates were significantly higher in patients who quit smoking compared to those who continued (85% versus 61%). This higher probability of survival was observed across all evaluated subgroups, including light versus moderate and heavy smokers, and patients with early and late-stage tumors. Similarly, five-year progression-free survival rates were significantly higher among patients who quit smoking (80% versus 57%). In multivariable, time-dependent regression models adjusted for age of diagnosis, presence of other chronic health conditions, number of pack years, alcohol drinking status, tumor stage, and treatment received during follow-up, smoking cessation was significantly associated with a lower risk of all-cause mortality, disease progression, and kidney cancer-specific death. The results were comparable when excluding from the analysis patients who quit smoking three and twelve months after diagnosis, and this is important because inclusion of these patients might have biased results considering that these patients might have survived longer and thus had more chance to quit smoking.  So, in conclusion, smoking cessation among patients diagnosed with renal cell carcinoma was associated with a 50% lower risk of death, a 46% lower risk of cancer-specific death, and a 55% lower risk of disease progression. These results are extremely important and informative as they reinforce the need to promote smoking cessation among patients diagnosed with renal cell carcinoma since the observed clinical benefit was at least similar to that of currently employed or emerging targeted and immunotherapy treatments. The second article by Dr. Vidrine and colleagues is titled "Efficacy of a Smoking Cessation Intervention for Survival of Cervical Intraepithelial Neoplasia or Cervical Cancer: A Randomized Control Trial)". As for many other cancers, we know that smoking is a significant risk factor for the development of cervical cancer. Furthermore, smoking after a diagnosis of cervical intraepithelial neoplasia or cervical cancer was associated with poor treatment response, increased risk of recurrence and development or worsening of other chronic diseases over the survivorship period. Cervical cancer frequently affects younger women, those with low socioeconomic status, and also minority groups. Previous data obtained specifically in these groups showed reduced access to smoking cessation intervention and consequently worse consequences from continued smoking. Consequently, the development of effective interventions to improve smoking cessation in these populations is of critical importance. The study by Dr. Vidrine and colleagues included smoking patients diagnosed and treated for cervical intraepithelial neoplasia or cervical cancer, and not already using nicotine replacement therapy. As per clinical guidelines, patients received 12 weeks of combination nicotine replacement therapy with a patch plus lozenge, and with randomized one-to-one to a standard treatment group that received educational material and a letter referring to states’ tobacco cessation quick line at baseline three and six months or to the experimental intervention group. The experimental group received the standard treatment plus a novel 12 months intervention based on the Motivation and Problem-Solving approach or MAPS, aiming at facilitating and maintaining behavioral change. The intervention was co-developed with survivors of cervical cancer who smoked to target specific needs regarding smoking cessation, healthy behaviors, and other survivorship issues. The intervention was articulated on six telephone counseling sessions that were delivered over 12 months based on the needs of each patient. After randomization, patients were followed up prospectively at 3, 6, 12, and 18 months. The primary outcome of the study was self-reported seven-day point prevalence abstinence from smoking at 18 months, so, six months after the end of the intervention. The secondary outcome was biochemically confirmed seven-day point prevalence abstinence evaluated on saliva.   The study published in JCO* reports results among 194 patients. The majority were non-Hispanic White, had low socioeconomic status, and were diagnosed either with cervical intraepithelial neoplasia or stage I cervical cancer. Unfortunately, the trial failed to demonstrate its primary outcome. At 18 months, the percentage of patients who quit smoking was similar, 14% in the MAPS group versus 12% in the standard treatment group. However, when examining longitudinally the percentage of patients who quit smoking at each of the four-time points, a significant interaction was observed between the smoking condition and the timing assessment. Consequently, the authors decided to investigate the percentage of patients who quit smoking at every single time point. In this analysis, a significantly higher percentage of patients who quit smoking was observed at 12 months in the experimental group, equal to 26% for the MAPS group intervention versus 12% in the standard treatment group. Furthermore, patients who completed at least four MAPS sessions had a significantly higher abstinence rate at twelve months, 38% compared to 8% for those who completed zero to three sessions.  So, in conclusion, this trial and the MAPS intervention resulted in a higher rate of abstinence at 12 months, although a considerable number of survivors relapsed six months after the end of the intervention, thus dissipating the overall effect. However, the results of this trial are extremely important because they highlight the need for further research in the field, first to improve patient engagement to smoking cessation intervention, and second, to promote sustained behavioral change that can be maintained even after the end of the active intervention phase.   Finally, the third article by Dr. Hohl and colleagues is titled "Integrating Tobacco Treatment into Oncology Care: Reach and Effectiveness of Evidence-Based Tobacco Treatment across National Cancer Institute Designated Cancer Centers.)" As highlighted by the previous two articles, smoking cessation is paramount for patients diagnosed with cancer and survivors of cancer. Despite the existence of specific NCCN guidelines on the topic, there is considerable evidence that smoking cessation is not commonly addressed in cancer care. So, as part of the Cancer Moonshot program, the Cancer Center Cessation Initiative was launched in 2017 with the objective of integrating evidence-based tobacco treatment into cancer care. The study by Dr. Hohl and colleagues aimed to assess the reach and effectiveness of tobacco treatment programs across NCI-designated centers included in the Cancer Center Cessation Initiative using six months of data collected from January to June 2021.  This cross-sectional study focused on two main outcomes. The first one, treatment reach, was defined as the proportion of smoking patients who received at least one tobacco treatment component over the total number of patients who reported current smoking examined in the included NCI centers. The second outcome was smoking cessation effectiveness, defined as the proportion of patients who reported seven-day point prevalence estimates of smoking cessation over the total number of patients who received at least one tobacco treatment component in the centers.  This study examined data from 28 NCI-designated centers where more than 600,000 patients were evaluated and treated. Median smoking prevalence was 7%, median reach was around 15%, and median effectiveness was around 18%. Some differences in reach and effectiveness were noted according to center characteristics, tobacco treatment program characteristics, implementation strategies, and components of the tobacco treatment programs. Smaller centers had higher reach but lower effectiveness, whereas the opposite was observed for larger centers. Additionally, centers with higher smoking prevalence had both higher reach and higher effectiveness. The centers that were implementing tobacco treatment programs center-wide had higher reach and similar effectiveness compared to centers where these programs were implemented only in part. A slightly higher effectiveness was observed in centers that targeted only outpatients, possibly due to different patterns of care and clinical outcomes among inpatients. eReferral systems to smoking cessation quick lines that were used by 90% of the centers were associated with increased effectiveness when a closed-loop system was implemented.  Regarding the type and the component of the tobacco treatment programs, almost all centers offered at least four quick line referrals at the second higher median reach of 17% and also effectiveness 19%. Face-to-face counseling with tobacco treating specialists had the highest median effectiveness, almost 20%. All the other components, including pharmacotherapy, telephone-based counseling, and point-of-care counseling, had similar median reach and effectiveness.   Overall, these results are important as they are able to inform future resource allocation, tobacco treatment program design, and implementation according to center characteristics in order to improve reach and effectiveness of these tobacco treatment programs.   This is Davide Soldato, and in this episode of JCO Article Insights*, we discussed three articles on the topic of smoking cessation. The first article, by Dr. Sheikh and colleagues, described clinical outcomes among patients who quit smoking after a diagnosis of renal cell carcinoma and demonstrated that those patients who quit had increased survival benefits. The second article, by Dr. Vidrine and colleagues, reported the efficacy results of a novel intervention to promote smoking cessation among patients diagnosed and treated with cervical intraepithelial neoplasia or cervical cancer. The second article showed that, although the primary outcome was not reached, a higher percentage of patients quit smoking with this novel intervention at twelve months. Finally, the third article, by Dr. Hohl and colleagues, examined characteristics and implementation strategies of tobacco treatment programs among NCI-designated centers, and the results of this study will be important to improve the reach and effectiveness of this program over the years.   Thank you for your attention and stay tuned for the next episode of JCO Article Insights.*   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.*  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  Show Notes: Like, share and subscribe) so you never miss an episode and leave a rating or review. Articles Smoking Cessation After Diagnosis of Kidney Cancer Is Associated With Reduced Risk of Mortality and Cancer Progression: A Prospective Cohort Study) Efficacy of a Smoking Cessation Intervention for Survival of Cervical Intraepithelial Neoplasia or Cervical Cancer: A Randomized Control Trial) Integrating Tobacco Treatment into Oncology Care: Reach and Effectiveness of Evidence-Based Tobacco Treatment across National Cancer Institute Designated Cancer Centers.) Find more articles from the May 20 issue).