Effective Cessation Treatment for Patients with Cancer Who Smoke – The Fourth Pillar of Cancer Care

For half a century, the practice of evidence-based oncology care has depended on three primary intervention strategies: surgery, radiation therapy, and chemotherapy. These three pillars are buttressed by compelling data showing that they improve outcomes with the incident cancer as well as extend life overall. Despite the effectiveness of these intervention strategies, and newer approaches such as immunotherapies, cancer remains a huge health problem that exacts immense human and economic costs. A recent American Cancer Society study shows that about 1.7 million new cancer cases are projected in the US in 2019; about 1660 Americans are expected to die of cancer each day.¹ The Agency for Healthcare Research and Quality estimates total healthcare expenditures for cancer of about $80 billion in the United States in 2015. These tragic outcomes are linked by a common cause: tobacco use, which is the leading preventable cause of cancer and responsible for approximately 30% of all cancer deaths each year.²

The 2014 Report of the Surgeon General³ summarized a little recognized set of facts; continued smoking after cancer diagnosis is associated with significant increases in: all-cause mortality; cancer specific mortality; and second, primary cancers.³ The different recovery trajectories observed in former smokers and individuals who continue to smoke post-diagnosis attests to the great value in promoting cessation amongst oncology patients and cancer survivors who smoke, warranting its designation as the 4^th pillar of cancer care.

The recently established NCI Moonshot program, the Cancer Center Cessation Initiative (C3I), is intended to enhance the reach and effectiveness of smoking treatment delivered to oncology patients.⁴ This initiative recognizes both the centrality of smoking treatment for cancer patients as well as its neglect; few NCI-designated Cancer Centers provide adequate smoking treatment to their patients who smoke.⁵ The C3I initiative, and other research,⁶ shows that effective smoking treatment depends critically on three factors: 1) the adoption and support of such treatment by healthcare system leaders, clinicians, and other decision makers; 2) the reach of smoking treatment among cancer patients who smoke, and 2) the effectiveness of the smoking treatment amongst cancer patients who use it.

The MD Anderson program described by Cinciripini and his colleagues in this issue of JAMA Oncology⁷ focuses on the elements of a model cessation treatment for cancer care. It shows that an intense smoking treatment program involving extended counseling and pharmacotherapy can produce impressively high rates of smoking cessation amongst cancer patients: rates that will pay-off in terms of decreased mortality and occurrence of second primary cancers. However, the promise of such effective smoking treatment will not be realized unless the treatment is adopted and supported by key oncology and healthcare stakeholders and unless it achieves good reach into the population of oncology patients who smoke. Importantly, this population should include cancer survivors, a population that is projected to increase dramatically over the next 20 years and who will likely suffer from comorbidities and chronic conditions affected by smoking.⁸

There is a long and dismal history of attempts to enhance smoking treatment reach and effectiveness in primary care. Over many years, numerous individuals and groups repeatedly called for improved smoking treatment in primary care. These calls went essentially unanswered for over half a century. Despite repeated cogent arguments, smoking treatment in primary care did not appreciably budge until recently: far too few smokers were advised to quit; fewer still were offered and inducted into smoking treatment; and many primary care clinicians neglected to address smoking with their patients.⁹ Despite the availability of proven smoking treatments, feasible treatment delivery systems, and compelling evidence of patient benefit, a remarkably small percentage of primary care patients were urged to quit and provided evidence based treatment. Only recently, in part as a result of external forces (e.g., Meaningful Use requirements), have rates of smoking intervention increased in primary care.¹⁰ It is vital that we not ignore lessons from the past; i.e., we need to adopt strategies in cancer care that we now know increase smoking treatment delivery in other healthcare contexts.

Research on the implementation of smoking treatments suggests that the following strategies support the adoption and reach of smoking treatment programs in healthcare.

Steps that will promote smoking treatment adoption in cancer care include:

• A consensus standard for minimal levels of cessation care with regard to smoker identification, advice to quit, and offer of and referral to smoking treatment. These standards should be developed through a collaborative effort involving public and private entities, including NCI, ACS, ASCO, the Lung Cancer Roundtable and representatives of leading oncology organizations and centers.

• Indices of smoking treatment must be automatically and consistently indexed by EHR based data collection for use by healthcare report cards, NCI, professional oncology organizations, hospital/healthcare system leadership, and oncology clinics and clinicians to evaluate progress in delivering smoking related cancer care.

• EHR programming guides and other resources must be developed and disseminated to promote the implementation and use of effective smoking intervention workflows in cancer care. The C3I program has been tasked by NCI to produce such guides.

• Develop resources that foster the universal adoption of smoking treatment in cancer care. Key elements for successful adoption into busy oncology clinical settings include efforts to: reduce clinician burden, enhance compatibility with clinical care workflow, and provide patients with easy access to multiple treatment options.

• A new funding emphasis to support research on the long-term health and economic benefits of smoking treatment in oncology patient populations. An important need remains for additional research to advance the clinical and business case for intervening with smoking in cancer care.

Steps that will promote smoking treatment reach in cancer care include:

• Timely corrective actions such as provider feedback and training when EHR data show that clinicians are not meeting standards for the delivery of the essential elements of cessation clinical care (e.g., identification of smokers, advice to quit, offer of treatment, referral and delivery of treatment).

• Tailored and personalized outreach that motivates smokers to try treatment and that affords ready access to smoking treatment without requiring an oncology visit.

• Low barrier smoking treatment delivery mechanisms such as phone and telemedicine routes that increase treatment access and reduce patient burden.

• Warm hand-offs that directly connect patients with smoking treatment resources during a cancer healthcare visit or hospitalization, eliminating the significant drop-off in treatment connection that occurs if smokers must respond to later phone calls or letters from smoking treatment personnel.

• Opt-out strategies that deliver smoking treatment to all patients who smoke unless it is explicitly refused.

The paper by Cinciripini and his colleagues impressively shows that a highly intensive smoking treatment can lead to sustained cessation in almost half of oncology patients who smoke. Offering such treatment with strategies that increase its adoption and reach across oncology services and patients would, no doubt, yield tremendous benefits in terms cost savings, fewer oncology treatment complications, and decreased mortality. It is time to implement the 4^th pillar of comprehensive cancer care by taking steps to make highly effective smoking treatment an integral and essential component of cancer care for patients who smoke. Providers of oncology care would never countenance withholding chemotherapy, radiation therapy, or surgery for cancer patients who need it; the failure to deliver smoking treatment to cancer patients who smoke should excite similar intolerance.