Presentation on theme: "NYS Collaborative Conference Call May 2, 2012"— Presentation transcript:
1NYS Collaborative Conference Call May 2, 2012 Overcoming Barriers IN THE Treatment of tobacco Use with your cancer patientsJamie Ostroff, PhDDirector, MSKCC Tobacco Cessation ProgramChief, Behavioral Sciences ServiceMemorial Sloan-Kettering Cancer CenterNYS Collaborative Conference CallMay 2, 2012
2DisclosureI have received research support from Pfizer for a study examining the use of varenicline with tobacco- dependent, breast cancer patientsI will not be discussing any product that is investigational or not labeled for the use under discussion
3Approximately 443,000 U.S. Deaths Annually Attributable to Cigarette Smoking Source: MMRW 2008; 57 (45):
4Health Consequences of Smoking CancersAcute myeloid leukemiaBladder and kidneyCervicalEsophagealGastricLaryngealLungOral cavity and pharyngealPancreaticPulmonary diseasesAcute (e.g., pneumonia)Chronic (e.g., COPD)Cardiovascular diseasesAbdominal aortic aneurysmCoronary heart diseaseCerebrovascular diseasePeripheral arterial diseaseReproductive effectsImpaired fertility in womenPoor pregnancy outcomes (e.g., low birth weight, preterm delivery)Infant mortalityOther effectsCataract, osteoporosis, periodontitis, erectile dysfunctionThe 2004 Surgeon General’s Report on the health consequences of smoking describes a long list of diseases with sufficient evidence to infer a causal relationship with smoking. These are summarized below.CancerAcute myeloid leukemia, bladder and kidney, cervical, esophageal, gastric, laryngeal, lung, oral cavity and pharyngeal, and pancreatic.Pulmonary DiseasesAcute respiratory illnesses:Upper respiratory illnesses (rhinitis, sinusitis, laryngitis, pharyngitis)Lower respiratory illnesses (bronchitis, pneumonia)Chronic respiratory illnesses:Chronic obstructive pulmonary diseaseRespiratory symptoms (cough, phlegm, wheezing, dyspnea)Poor asthma controlReduced lung functionCardiovascular DiseasesAbdominal aortic aneurysm, coronary heart disease (angina pectoris, ischemic heart disease, myocardial infarction), cerebrovascular disease (transient ischemic attacks, stroke), and peripheral arterial disease.Reproductive EffectsReduced fertility in women, pregnancy and pregnancy outcomes (preterm, premature rupture of membranes, placenta previa, placental abruption, pre-term delivery, low infant birth weight), infant mortality (sudden infant death syndrome)Other EffectsCataract, osteoporosis (reduced bone density in postmenopausal women, increased risk of hip fracture), periodontitis, peptic ulcer disease (in patients who are infected with Helicobacter pylori), and poor surgical outcomes (poor wound healing, respiratory complications)♪ Note to instructor(s): For more detailed information and literature citations regarding risks for these tobacco-related illnesses, refer to the optional Pathophysiology of Tobacco-Related Disease module or the Surgeon General’s Report atU.S. Department of Health and Human Services (USDHHS). (2004). The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.
5Estimated Number of Cancer Survivors in the United States: 1971 to 2008 Source: SEER Cancer Statistics Review, , National Cancer Institute.
6Risks of Persistent Smoking for Cancer Patients Reduces survivalIncreases the risk of disease recurrenceIncreases the risk of second primary cancersPoorer treatment responseDecrease in effectiveness of treatmentReduces quality of lifeIncreases risk of other tobacco-related comorbid conditions (CVD, COPD)Worsen treatment side effect (surgery, radiation, chemotherapy)
7Surgical Complications Increased complications from general anesthesiaIncreased risk of pulmonary complications (pneumonia, reintubation, bronchospasms)Detrimental effects on wound healingCompromised capillary blood flowIncreased vasoconstrictionIncreased risk of wound infectionQuitting smoking at least one month prior to surgery is most beneficial
8Radiation Complications Lower treatment response ratesLower overall survival12Greater need for hospitalizationMore frequent treatment complications (e.g., osteoradionecrosis, mucositis, poor pain control, need for feeding tube, pharyngeal stricture13Impaired resumption of voice quality post-radiation14
9Chemotherapy Complications Diminished treatment response 15-16Increased side effects (e.g., immune suppression, weight loss, fatigue, pulmonary cardiac toxicityIncreases drug toxicityIncreases infection
10Health Benefits of Smoking Cessation: Cancer-Specific Improved survivalFewer treatment complicationsLower risk of peri- and post-operative complicationsImproved pulmonary health and less need for pulmonary rehabilitationImproved surgical wound healing and less risk of infectionGreater likelihood of shorter hospitalization and surgical timeLess dry mouth, mucositis, tissue and bone necrosisImproved treatment efficacyReduced risk of disease recurrenceReduced risk second primary cancerImproved mastery and controlBetter quality of life
11Smoking Prevalence in Adult Survivors by Cancer Site Method: random-digit dialing of U.S. adults about use of cancer-related information and cancer beliefs. Sample: 619 cancer survivors and 2,141 participants without a history of cancer from the original 6,369 Health Information National Trends Survey (HINTS) respondents.Mayer et al., 2007 HINTS Data
12Populations Estimates of Smoking Prevalence in Childhood and Adult Cancer Survivors CCSS; Emmons et al., 2002NHIS; Bellizzi et al., 2005
13Persistent smoking is prevalent among cancer patients With much disease-specific variation, as many as % of cancer patients are estimated to be persistent tobacco usersMost cancer patients express interest in quittingLike other smokers, nicotine addiction and psychological dependence on smoking are formidable quitting barriers.
14Risk Factors for Continued Smoking in Adult Cancer Survivors Younger ageLess intensive medical treatmentEarly stage diseaseNon-tobacco-related ca dxHeavy nicotine dependenceLow motivationLow self-efficacyDepression/Alcohol
15Smoking status recommended as core clinical and research data element It is “incumbent on the cancer care community to incorporate effective tobacco cessation as an integral component of quality cancer care” (ASCO, 2009)Smoking status recommended as core clinical and research data elementTobacco cessation counseling recommended as standard of quality careASCO, 2009
16Recommended that Cancer Centers integrate assessment and treatment of tobacco use into routine clinical careCall for more research on developing and evaluating cost-effective cessation treatment delivery models in cancer careMorgan, et al 2011
17Tobacco Cessation Treatment Patterns of Oncology Providers (n=74) NVFVAsk82.4%28%Advise86.5%---Assist30%ArrangeWeaver et al 2012
18Patient-Reported Barriers for Smoking Cessation Pressure to quit abruptlyHigh levels of nicotine dependence and severe withdrawal symptomsHigh levels of psychological distressLoss of a coping strategyLow quitting self-efficacy (confidence) due to multiple prior failed quit attemptsStigma
19Smoking and Cancer Patients The good news Tobacco control policies are effective and have change social norms about smokingThe bad news Many smokers report perceived stigma associated with reluctant disclosure of diagnosis, psychological distress, decreased help-seeking>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>>>>Tobacco dependence is a chronic relapsing condition maintained by nicotine addictionBiobehavioral model of nicotine addictionGenetic susceptibilityHistoric misinformation about dangers of smoking
20Barriers Facilitators Provider-reported barriers and facilitators of treating tobacco dependence in cancer care settingsBarriersFacilitatorsHealth benefitsPatient wants to quitExpected part of my roleCessation will decrease risk of recurrenceCessation will decrease side effectsConfidence in ability to help people stop smokingSuccessful past experiencesAvailability of referral sourcesAdministrative supportLack of patient motivationLack of timeLack of skillsLack of knowledge about how to help patients quitDon’t want to add to patient’s stressDon’t want patient to feel guiltyPoor prognosisSource: Sarna et al., 2000
21MSKCC Tobacco Cessation Program: Clinical Objectives To identify all smokers at MSKCCTo implement a comprehensive, evidence-based tobacco cessation and relapse prevention program tailored to meet the needs of all Memorial Sloan- Kettering Cancer Center (MSKCC) patients and employeesTo monitor and implement continuous improvement in standards of care of tobacco dependenceMemorial Sloan Kettering's comprehensive smoking cessation objectives includeidentifying all smokers at MSKCC,providing stepped care evidence based treatment of tobacco dependence tailored to the special needs of cancer patients and their familiesand to monitor and implement continuous improvement of cessation quality of care
22United States PHS Guidelines: Treating Tobacco Use and Dependence This is the third publication of this guideline. The original was in 1996 and was based on about 3,000 research articles. The guideline was then revised in 2000 which covered an additional articles. The current release, for 2008, adds an additional 2,700 articles representing, then, a summary of about 8,700 tobacco research articles.Initial Guideline publishedLiterature fromApprox. 3,000 articlesRevised Guideline publishedLiterature fromApprox. 6,000 articlesUpdated Guideline publishedLiterature fromApprox. 8,700 total articles
23STEP 2: MODERATE INTENSITY MSKCC Tobacco Cessation Program Stepped-Care ModelSTEP 2: MODERATE INTENSITYFirst-line pharmacotherapyBrief motivational and cessation counselingArrange referral and/or follow-upSTEP 1: MINIMUM INTENSITYIdentify all current smokersPersonalized adviceSelf-help materialsSTEP 3: MAXIMUM INTENSITYClinic treatment (individual counseling)Address psychiatric, substance abuse comorbidityCombination pharmacotherapyLong-term follow-up and maintenance
24MSKCC Tobacco Cessation Program Timeline Hired 1st Tobacco Treatment Specialist (TTS)Established case finding and referral mechanismsApproval of all cessation medications on hospital formularyDeveloped patient education cessation Medication Fact CardsNeeds assessment and Performance Improvement Project >> Oncology NursesEstablished Clinical Triaging CriteriaDeveloped Patient Education BookletHired 2nd Tobacco Treatment SpecialistStandardized Intake and Follow-up FormsTranslation of Patient Education Materials(Spanish/Russian)Developed Smoking Cessation DatabaseDeveloped and promoted clinical standards of careIntensive Staff Education and TrainingRefined Smoking Cessation DatabaseImproved electronic referral procedure (OMS)MSKQuits! Employee Tobacco Cessation ProgramNYC Tobacco TaxSmoke Free Workplace LegislationTelevision Ad CampaignJuly 2002 NYC Tobacco TaxMarch 2003 Smoke Free Workplace LegislationJanuary 2006 Television Ad CampaignJune 2008 NYS Tobacco TaxJuly 2009 Smoke Free Hospital LegislationNYS Tobacco TaxNYC Smoke Free Hospital Legislation2009-Tobacco Free Hospital PolicyQI ProjectsJoint Commission Metrics for Screening and Treating Tobacco Use
25Responsibilities of Tobacco Treatment Specialists in Oncology Setting Screen all patients for current tobacco useConduct intake evaluation and tobacco use history interviewReview chart and liaise with oncology care teamProvide education regarding personalized risks of persistent smoking and benefits of cessationReview smoking cessation medications options/shared decision making (contraindications, side effects, outcomes)Establish quit plan/dateProvide brief, telephone-delivered, behavioral counseling for motivational enhancement, coping with smoking urges and relapse preventionMake referral for intensive cessation counseling PRN
26ASK: Tobacco Use Screener In the past 30 days, have you smoked cigarettes or used any other forms of tobacco (cigars, pipe, smokeless tobacco)?Every day*Some days*Not at all*Tobacco use screening is routinely assessed on Ambulatory and Inpatient Adult Health Screening FormsSource: Modified BRFSS, Joint Commission “compliant” tobacco screener
27ADVISEProvide patient with specific education about risks of persistent smoking and the benefits of quitting.Offer advice on the safety and efficacy of cessation medications as well the benefit of seeking behavioral counseling.
28Lastly, book marks were written to address the Health Benefits of becoming smoking free when diagnosed with cancer and the overall Health benefits gained when becoming smoke-free.. Currently we have 4 bookmarks that are being distributed in our outpatient facilities and a 5th one in production. The 5 bookmarks written are for Lung cancer, Bladder cancer, Cervical cancer, Head and Neck cancer and Breast cancer.
29PRESCRIBEUse of cessation medication reduces acute nicotine withdrawal (e.g., restlessness, irritability, cravings, difficulty concentrating).Use of cessation medication also increases the likelihood of successful cessation.
31Special Considerations in Using Cessation Pharmacotherapy with Cancer Patients Medication recommendations should consider potential contraindications and side effectsNausea and vomiting are common side effects of chemotherapyInsomnia and sleep impairment are commonDry mouth and oral mucositis may preclude use of NRT lozenge/gumPatients scheduled for reconstructive surgery (breast, head and neck) are advised to refrain from peri-operative NRTPatients with brain tumors and brain mets may be at-risk for seizures (Zyban?)Patients with kidney cancer may have impaired renal function (Chantix?)Standard dosage recommendations are dependent upon smoking rate/patterns and patient’s prior medication use experience
32ReferRefer your patient to the New York State Smokers’ Quitline 866-NY-QUITS ( ) nysmokefree.com or Your local Tobacco Cessation Treatment Specialist
33Strategies to Improve Uptake of Referral to Tobacco Cessation Services Improve quality of empathic, non-judgmental communication between provider-patientAcknowledge and encourage expression of negative feelings (guilt, shame, blame)Validate and normalize emotional reactionsPraise patient’s coping effortsExpress willingness to helpMotivational counseling
354/14/2017Smoking and Tobacco Use are Important to Address in the Oncology SettingRates of current smoking at diagnosis among patients with cancer varies.Patients with cancers less strongly associated with smoking have lower long-term quit rates.Overall, up to 30-50% of cancer patients smoking at diagnosis do not quit, or relapse following initial quit attempts.Relapse even occurs among patients who quit ³ 1 year earlierWalker et al., CEBP, 2006; Cooley et al., Lung Cancer, 2009;Gritz et al., Principles and Practice of Oncology, 8th edition, Ed(s) DeVita et al., 2008
36Recommended Standard of Care for Promoting Smoking Cessation in Cancer Care Settings Ask about tobacco use at initial and follow-up visitsDocument current and changes in tobacco use status in medical chartProvide personalized advice and education about cessation benefits and risks of continued tobacco useProvide cessation assistance and/or refer to Tobacco Treatment Specialists (TTS)Document changes in smoking status and analyze utilization trends and outcomes for continuous quality improvementASCO, 2009
37BibliographyTobacco cessation and quality cancer care. J Oncol Pract, (1): p. 2-5.Morgan, G., et al., National Cancer Institute Conference on Treating Tobacco Dependence at Cancer Centers. Journal of Oncology Practice, (3): pNCI: Smoking cessation and continued risk in cancer patients (PDQ).MMR weekly- Cigarette Smoking Among Adults- United States, : /09/07Bellizzi, K., et al., Health behaviors of cancer survivors: examining opportunities for cancer interventions. Journal of Clinical Oncology, 2005, 23(24): pgBrowman, G.P., et al., Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med, (3): pDaniell, H.W., A worse prognosis for smokers with prostate cancer. J Urol, (1): pMason, D.P., et al., Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database study. Ann Thorac Surg, (2): p ; discussionZevallos, J.P., et al., Complications of radiotherapy in laryngopharyngeal cancer: effects of a prospective smoking cessation program. Cancer, (19): pKarim, A.B., et al., The quality of voice in patients irradiated for laryngeal carcinoma. Cancer, (1): pZhang, J., et al., Nicotine induces resistance to chemotherapy by modulating mitochondrial signaling in lung cancer. Am J Respir Cell Mol Biol, (2): p