Smoking Cessation in the Oncology Setting Scott Antle Suzanne Drodge Wednesday’s at Noon Lecture Series March 30, 2017

Disclosures

•  Therearenofinancialoreduca/onaldisclosures

Objectives •  Presentevidenceastotheclinicalandeconomicbenefitof

smokingcessa/ona9eracancerdiagnosis•  Demonstratetheimpactofcon/nuedsmokinguponcancer

treatment•  Highlightworkbeingplannedtointegratesmokingcessa/oninan

ambulatoryoncologyse?ng•  Demonstratethesuppor/veroleofprimarycareprovidersin

smokingcessa/ona9eracancerdiagnosis

Overview •  CancerCareProgram•  TheTobaccoAddic/on•  ImpactonCancerTreatment•  BenefitsofSmokingCessa/onA9eraCancerDiagnosis

•  Pharmacotherapy•  TobaccoCessa/onandRelapsePreven/oninCancerCare

Cancer Care Program

•  TheCancerCareProgramoperatesoutoftheDr.H.BlissMurphyCancerCentreinSt.John’s–  RegionalCancerCentresinGander,GrandFalls-Windsorand

CornerBrook

•  Chemotherapyprovidedin~20sitesacrossNL•  51siteswithtele-oncology•  Approximately200healthcareproviders

–  Oncologists,physicians,nursing,socialwork,medicalphysics,radia/ontherapy,nutri/on,clericalsupport,administra/on,cancerregistry,IT

2016 Canadian Cancer Statistics (NL)

Newcases:•  Males:2,000•  Females:1,900•  Total:3,900(ASI:610.7/100,000)*Deaths:•  Males:780•  Females:670•  Total:1,450(ASM:228.7/100,000)*

Tobacco & Cigarette Smoke

•  Over 7000 constituents in cigarette smoke

•  60+ known carcinogens •  ++ additives

– Enhance consumption –  Increase flavor –  Increase addiction

Tobacco & Cigarette Smoke

Tobacco: A Powerful Addiction

Cigarecesmokingproducesarapiddistribu/onofnico/netothebrain,withdruglevelspeakingwithin10secondsofinhala/on.Theacuteeffectsofnico/nedissipatewithinafewminutes,causingtheneedtocon/nuerepeatedintakethroughouttheday.

The Addiction: Molecular and Behavioral

Tobacco: A Powerful Addiction

Tobacco & Cancer •  Largestsinglecontributortocancerrisk•  Smokingcontributesto30%ofallcancerdeaths•  Smokingaccountsforapproximately85%oflung

cancerdeaths•  Sufficientscien/ficevidencetolinktobaccocausallyto

15othercancers:–  oralcavity,nasalcavityandparanasalsinuses,pharynx,larynx,

esophagus,stomach,liver,pancreas,cervix,ovary,kidney,ureter,bladder,bowel,acutemyeloidleukemia

•  Somelimitedevidenceforalinkbetweentobaccosmokingandbreastcancer

2014 US Surgeon General’s Report

•  Studies between 1990-2012 –  About 400 studies with over 500,000 patients

•  Evaluation of smoking effects on: 1.Overall mortality/survival 2.Cancer-specific mortality/survival 3.Response to treatment 4.Toxicity of treatment 5.Cancer recurrence 6.Risk of second primaries

2014 US Surgeon General’s Report Conclusions

–  In cancer patients and survivors, the evidence is sufficient to infer a causal relationship between cigarette smoking and adverse health outcomes. Quitting smoking improves the prognosis of cancer patients.

–  In cancer patients and survivors, the evidence is

sufficient to infer a causal relationship between cigarette smoking and increased all-cause mortality and cancer-specific mortality.

2014 US Surgeon General’s Report Conclusions

•  Incancerpa/entsandsurvivors,theevidenceissufficienttoinferacausalrela0onshipbetweencigarecesmokingandincreasedriskforsecondprimarycancersknowntobecausedbycigarecesmoking,suchaslungcancer.

•  Incancerpa/entsandsurvivors,theevidenceis

sugges%vebutnotsufficienttoinferacausalrela%onshipbetweencigarecesmokingandtheriskofrecurrence,poorerresponsetotreatment,andincreasedtreatment-relatedtoxicity.

Tobacco Cessation& Cancer Care

Tobacco Cessation and Cancer Care

•  Cigarecesmokeini/atestumorgrowthandmay

promotetumorprogression.•  Stoppingtobaccouseisoneofthebestthingsa

pa/entcandotohelptheircancertreatment.•  TheUSSurgeonGeneralindicatedthatbecoming

tobaccofreecanimproveoutcomesby~40%.

Tobacco Cessation and Cancer Care

•  EvidencesupportsSmokingcessa/onbecomingastandardofcarewithinanycancertreatmentplan

•  ItisarguedthatIfyouareabletotreatwith

chemotherapyand/orradiotherapyforthepurposeofextendingsurvivorshipthenweneedtoconsiderapa/entssmokinghistoryandoffersmokingcessa/on

Clinical Evidence

• “…theevidenceisclearthattobaccouseinpa/entswithcancerleadsto…”

•  decreasedtreatmentefficacyandsafety•  decreasedsurvival•  decreasedqualityoflife•  increasedtreatment-relatedtoxicity•  increasedriskofcancerrecurrence•  Increasedriskofsecondprimarytumours

Clinical Evidence

•  “Datasuggestthattobaccocessa%oncanimproveoutcomesandsurvivalinpa%entswithcancer,yetfullexecu%onofevidence-basedcessa%oninterven%onsisinfrequentinoncologyse?ngs.”–  Dr.GrahamWarren,TheParadigmShi9

Impact on Cancer Treatment •  Thereareseveraltreatmentop/ons

•  Surgery•  SystemicTherapy•  Radia/onTherapy•  Pallia/veCare

•  Con/nuedsmokinga9eracancerdiagnosisandduringac/vetreatmenthasasignificantimpactonoutcomesandtreatmentsideeffects

Tobacco use & treatment side effects

Chemotherapy Radiation Surgery • Exacerba/onofsideeffectsincluding:

•  Immunesuppression•  Weightloss•  Fa/gue•  Pulmonaryand

cardiactoxicity•  Increasedincidence

ofinfec/on• Mayalterthemetabolismand/ormechanismofac/onofchemotherapymakingitlesseffec/ve

• Reducedtreatmentefficacy• Increasedtoxicityandsideeffectstoinclude:

•  DryMouth(Xerostomia)

•  Oralmucosi/s(mouthsores)

•  Lossoftaste•  Pneumoni/s•  So9/ssueandbone

necrosis•  Poorvoicequality

• Increasedcomplica/onsfromanesthesia• Pulmonarycomplica/ons• Poorwoundhealing• Increasedriskofinfec/on

Smoking and Chemotherapy

•  Erlo%nib(e.g.NSCLCandPancreas)–  Loweroverallresponseinsmokersvsneversmokers–  Requiretwicethenormaldosetoproduceneededcircula/ng

levelsinsmokersversusnon-smokers•  Sheppardetal.(July14,2005).NEJM353:123-132.

•  Irinotecan(e.g.ColorectalcancerandSCLC)–  smokershad~40%lowersystemicexposuretotheac/ve

metaboliteSN-38comparedtonon-smokers•  VanderBoletal.(2007)JCO25:2719-2726.

Smoking and Molecular Therapy

•  StudybyVincenzi(2009)demonstratedthatac/vesmokingisassociatedwithlessclinicalbenefit(responseplusstablediseasein54%versus88%)thannon-smokers

•  Cetuximab(eg:colorectalandheadandneck)cigarece

smokingmayberesponsibleforadecreaseintheresponserateandleadtoalower/metoprogression(oftumor)fromcetuximab-basedtreatmentsforadvancedcolorectalcancerspa/entsamongsmokers.–  Vincenzietal.(August2009).BiologicalTherapy,945-949.

Smoking & Radiation Therapy

•  Smokerswhocon/nuetosmokeduringXRThaveasignificantlylowerrateofcompleteresponsetoradia0ontherapy(45%vs74%)and2-yearsurvival(39%vs66%)

•  Recentquicersweremorelikelong-termquicersthanthosewhocon/nuedtosmokeintermsoftheirlikelihoodofsurvivingat18months

•  BrowmanGPatal.NEJM1993–  Dr.JinkaSathya,Radia%ononcologistattheDBMCCco-author

Smoking and Therapeutic Response

Warren,GMKeynotepresenta/on,January2017

CS=con/nuedsmokingRT=radia/ontherapy

Tobacco Cessation •  Mosteffec/ve

–  behavioraltherapies,non-prescrip/onandprescrip/onmedica/onsareusedincombina/on.

•  Amul/disciplinaryapproachiscrucial•  Tobaccocessa/onmodelsarebriefandgoaldirected

–  5A’s–  3A’s–  2A’s1R

•  TobaccoCessa/on=ChangeManagement

Impact on Cancer Centers

•  Smokingcessa/onisacosteffec/vemethodtodecreaserecurrenceriskandimprovetreatmentoutcomes

•  Pa/entshavetheopportunitymaximizethebenefitoftheircancertreatmentwithsupportfromsmokingcessa/onclinics

•  Avoiding2ndlinecancertherapyimprovesqualityoflifeandiscosteffec/ve

Impact on Cancer Centers

Warren,GMKeynotepresenta/on,January2017

Impact on Cancer Centers

Smoking Cessation and Relapse Prevention

•  Offerabestprac/cesmokingcessa/onandrelapsepreven/onprograminanambulatoryoncologyse?ng

•  Supportavailabletocancerpa/entsreceivingac/vetreatment

•  Pilotprogram–  Head/neckandlungcancerpa/ents–  Pa/entsofferedclinicalappointment,medica/on,and

behavioralsupport–  Familymembersofferedbehavioralsupport

Key Deliverables to Planning a Cessation Program

•  ProgramModelandAlgorithm•  BestPrac/cereviewofotherprograms•  Rela/onshipBuilding(PrimaryCareProviders)•  Resourcedevelopment:

–  Clinicalguidelines–  Pa/entbrochure,guidebook–  Educa/onalpresenta/ons–  Communica/onsstrategy–  Pharmacotherapybusinesscase–  Educa/onalopportuni/es–  Programcostes/mates–  ProgramSustainabilityModel

Best Practice Smoking Cessation

• Ask• Advise• Referral

Screen

• Clinicalappointment• Pharmacotherapy• BehavioralThearpy

Counsel

• ClinicalfollowupAppointment

• AdjustPharmacotherapy• PCPSupport

Follow-up

Pharmacotherapy Considerations in Oncology

NRT• Mayirritateoralmucosa• Withheadandneckcancersmayexacerbatecondi/on• Contraindicatedforpre-opera/vesurgery

Varenicline(Champix)• Dosageconsidera/onsforpa/entsexperiencingnausea• Noevidenceonsafety/efficacy• Besttousewithbehavioralcounselling

Bupropion(Zyban)• Mayreduceappe/te• Concurrentuseoftamoxifenorprocarbazineiscontraindicated• Anxietymayincrease

Combina/onNRTandmedica/ons• Theaddi/onofnico/nepatchtoVareniclinedidnotcausesignificantchangesinsideeffectprofiles• Sideeffectsofcombina/ontherapyofthepatchandBupropionwerenotsignificantlydifferentversusbupropionalone

PharmacotherapyOp%ons

Pa%entscreened

ComboNRTNico/nePatch+Shortac/ngNRT(gum,inhaler,

lozenge)

Varenicline+NRT

Bupropion(Zyban)+NRT

Varenicline(Champix)

Bupropion

1st4weeksWeeks5-12Ifpreviousnotworking

AdoptedfromPharmacotherapyOp/onsfromtheCentreforAddic/onsandMentalHealth(CAMH)

Mo/va/onInterviewing:ChangeManagement

Role of Primary Care Provider

•  Priortoconsulta/onatthecancerprogramaskingandadvisingpa/entstoquitsmokinggivesthemaheadstartfortheircancertreatmentplan

•  PrimaryCareProvidersplayacri/calroleinacancerpa/entstransi/onintosurvivorship

•  Communica/onbetweenthecancerprogramandthePrimaryCareProviderisimportanttoensureposttreatmentpreventa/vecare

Role of Primary Care Provider

•  Althoughacutelyawareofthedangersofsmokingandtobaccouse,Primarycareprovidersmustbecomechampionsofposttreatmentcessa/on

•  Encouragepa/entstocon/nuetobesmokefree•  PrimaryCareProviderswillbeno/fiedthatpa/entshave

receivedcessa/onsupportatthecancerprogram.•  Con/nuetoaskaboutsmokingstatus•  Assistinaccessingaddi/onalcessa/onsupportspost

cancertreatment

References •  AmericanSocietyofClinicalOncology(ASCO).(2012).TobaccoCessa/onGuideforOncologyProviders.

AmericanSocietyforClinicalOncology.•  BrowmanGPI,W.G.(January21,1993).InfluenceofCigareceSmokingontheEfficacyofRadiotherapyinHead

andNeckCancer.NewEnglandJournalofMedicine,328(3):159-163.•  CanadianCancerSociety.(2016).CanadianCancerSociety'sAdvisoryCommiceeonCancerSta/s/cs.Canadian

CancerSta/s/cs2015.Toronto.•  CenterforAddic/onandMentalHealth(camh).(2016).CAMHcenterforaddic/onsandmentalhealth.

Retrievedfromwww.nico/nedependenceclinic.com•  SheppardMD,F.A.(July14,2005).Erlo/nibinPreviouslyTreatedNon-SmallCellLungCancer.NewEngland

JournalofMedicine,353:123-132.•  Stahl,S.M.(2008).Stahl'sEssen/alPsychopharmacology3rdEdi/on.Neuroscien/ficBasisandPrac/cal

Applica/ons.NewYork,NYUSA:CambridgeUniversityPress.•  USDHHS,U.S.(2014).TheHealthConsequencesofSmoking-50yearsofProgress.AreportoftheSurgeon

General.Atlanta,GA,USA:U.S.DepartmentofHealthandHumanServices,CentresforDiseaseControlandPreven/on,Na/onalCenterforChronicDiseasePreven/onandHealthPromo/on,OfficeofSmokingandHealth.

•  VanderBolJM,M.R.(2007).CigareceSmokingandIrinotecanTreatment:Pharmacokine/cInterac/onandEffectsonNeutropenia.JournalofClinicalOncology,25:2719-2726.

•  VincenziB1,S.D.(August2009).Cigarecessmokinghabitmayreducebenefitfromcetuximab-basedtreatmentinadvancedcolorectalcancerpa/ents.BiologicalTherapy,945-949.

•  Warren,G.(2017).SmokingandtheCancerPa/ent:ClinicalBehavioralandAdministra/veConsidera/ons.CanadianPartnershipAgainstCancer,SmokingCessa/oninCancerCaremee/ng,(pp.1-55).Ocawa.

Questions

Thank you!