The importance of effective smoking cessation and lung cancer screening programs, as well as practical strategies for implementing these programs, will be highlighted during an Education Session on June 4. The session, “Lung Cancer Screening and Prevention,” will include three presentations.*
Dr. Graham W. Warren
Photo courtesy of Julia Lynn
Tobacco use increases risk of overall mortality across all cancer disease sites and treatments, Dr. Warren said. Smoking and tobacco products alter cancer biology, promoting increased proliferation, angiogenesis, migration, invasion, metastasis, and resistance to cytotoxic cancer therapy. Citing data included in the 2014 Surgeon General’s Report “The Health Consequences of Smoking—50 Years of Progress,” Dr. Warren said that current smoking increases the risk of overall mortality by approximately 50%, increases the risk of cancer-related mortality by approximately 60%, increases the risk of second malignancy, and has strong associations with cancer treatment toxicity.1
Recent research has found that between 30% and 50% of patients had been using tobacco at the time of cancer diagnosis, with rates highest among those diagnosed with head and neck or lung cancers.2 No cancer treatments have been identified that yield better results in patients who smoke, and no biomarkers have been identified that can predict which patients will have adverse outcomes if they continue to smoke, Dr. Warren said.
“The adverse effects of smoking are generally ubiquitous across cancer as a whole, and addressing tobacco use is pertinent to the treatment of all patients with cancer,” Dr. Warren said. “We have found that 90% of oncologists ask their patients about tobacco use and approximately 80% give advice to their patients about smoking, but less than 40% actually help people try to quit smoking. The biggest barriers are lack of time, lack of resources, lack of experience, and lack of education about how to get people to quit smoking.
“Physicians need to ask their patients about tobacco use and current smoking and tell them that smoking is going to affect their cancer treatment outcome and that they must quit,” Dr. Warren continued.
Dr. Warren recommends physicians look to both the ASCO and the National Comprehensive Cancer Network guidelines as resources if they need guidance on how to help patients stop smoking. “All clinicians should either help people quit smoking or make sure they are connected with resources that provide evidence-based support, such as dedicated tobacco cessation programs,” he said.
During his presentation, Dr. Warren will highlight practical considerations for institutions that want to develop evidence-based tobacco cessation support systems. Before developing a program, however, an institution must consider its own clinical setting and opportunities for integrating tobacco treatment with medical management; resources available for assessing and addressing tobacco use; ways to assess tobacco use through electronic medical records or paper charts; how an individualized cessation approach will incorporate counseling, pharmacotherapy, and follow-up; and how to maintain the program.
“Providing evidence-based medicine through a sustainable process is critical to success,” he said.
Lung Cancer Screening
Session Chair Denise R. Aberle, MD, will discuss the challenges and benefits of lung cancer screening. Dr. Aberle is national principal investigator of the American College of Radiology Imaging Network component of the National Lung Screening Trial (NLST), which compared the efficacy of low-dose helical CT versus chest radiography for lung cancer screening.
The study enrolled more than 53,000 current and former heavy smokers aged 55 to 74 years at 33 sites across the United States. Patients who received low-dose helical CT scans had a 15% to 20% lower risk of dying from lung cancer than those who received standard chest X-rays. Adenocarcinomas and squamous cell carcinomas were detected more frequently at the earliest stage by CT, and small cell lung cancers were infrequently detected at early stages by either CT or chest X-rays.3
Dr. Abbie Begnaud
The screening program at Dr. Begnaud’s institution, the University of Minnesota Health, began in 2013. Screening is recommended for current and former smokers aged 55 to 74 years who have smoked at least a pack of cigarettes a day for 30 or more years and for current smokers or those who have quit within the past 15 years, according to NLST criteria.
During her presentation, Dr. Begnaud will discuss the early development of the program, including the patient questionnaire detailing risk factors for lung cancer, the structured reporting system for results, and methods of follow-up with patients about screening results.
Dr. Begnaud will also review the program’s challenges. Initially, orders for screening were fewer than had been expected, possibly because of uncertainty about insurance coverage. Even when exams were ordered, only 63% of exams were completed, a problem attributed, in part, to reimbursement uncertainty and out-of-pocket payment for the exam. Patient anxiety may have prevented many patients from scheduling exams, even if they had information about the need to do so, Dr. Begnaud said.
The system’s electronic health record tools were modified to comply with evolving requirements, including creation of a SmartSet—a bundle of orders and documentation related to a topic—for lung cancer screening. This SmartSet includes guidelines for clinicians about patient eligibility, required billing codes, suggested wording for a shared decision-making visit, orders for smoking cessation tools, and the imaging order.
In a recent evaluation of the program, the researchers found that approximately one-third of the orders were for patients whose eligibility for screening could not be confirmed. These patients had no documentation of smoking history, had a documented smoking history of fewer than 30 pack-years, or had quit smoking more than 15 years prior to the exam. Approximately 95% of the screening exams had been ordered during an office visit, but many had no documentation of counseling or of a shared decision-making visit with a credentialed provider.
Dr. Begnaud’s presentation will focus on the challenges of implementing a program and the lessons that can be learned by other health care systems working to design a similar program, including the need for reimbursement-driven enforcement of patient eligibility so that patients at high risk are most likely to benefit.
– Kathy Holliman, MEd