A new clinical practice guideline for smoking cessation in oncology patients encourages use of evidence-based pharmacotherapy, behavioral therapy, and close follow-up with re-treatment, if needed, said Peter Shields, MD, Deputy Director, the Ohio State University Comprehensive Cancer Center, Columbus, at the National Comprehensive Cancer Network (NCCN) 20th Annual Conference, held in March in Hollywood, Florida.
According to the American Association for Cancer Research Task Force on Tobacco, “virtually no institutions reported systematic and consistent mechanisms for fostering cessation,” said Shields.
Many cancer patients still smoke, and those who do have worse outcomes when treated for their cancer, he said, citing at least 1 study on the negative influence of smoking on the efficacy of radiation therapy in head and neck cancer.
Shields noted that cancer patients who smoke are typically more nicotine dependent and probably have a history of unsuccessful attempts to quit. The most effective treatment approach at any point in the NCCN guideline algorithm is a combination of pharmacologic therapy and counseling. Nicotine replacement therapy (NRT) alone may be no better than unaided quitting, and a dose-response relationship exists between the amount of therapy and success. “Brief counseling, even as short as 3 minutes, is better than no counseling,” said Shields. Behavioral therapy can take the form of individual in-person counseling, phone counseling, or group counseling.
Smoking status should be documented in patient health records and updated at regular intervals. Healthcare providers should discuss relapse and provide guidance for patients.
Smoking relapse may or may not warrant a change in therapy. “Sometimes smokers require repeated quit attempts with the same therapies as smoking slips, and relapses are common,” he said.
In addition to NRT, varenicline is considered a first-line pharmacologic treatment. Second-line pharmacologic options are varenicline plus NRT and bupropion plus NRT. Third-line options are varenicline plus bupropion with or without NRT, the tricyclic antidepressant nortriptyline, and the alpha-2 adrenergic receptor agonist clonidine.
Bupropion is contraindicated for patients with seizure risk, and users of varenicline and bupropion should be monitored for new or worsening neuropsychiatric issues. For NRT, there is no evidence that nicotine itself causes cancer or increases the risk of heart disease.
The guideline calls for an evaluation of the patient’s current smoking status, and “prioritizes those likely to relapse,” said Shields. “Current smokers and those smoking within 30 days are treated the same.” These patients should have their readiness to quit assessed. Those ready to quit should be given a personalized plan that includes the smoking cessation therapies mentioned above.
A review of the risks of smoking and benefits of quitting should be performed in patients who are not ready to quit. Barriers to quitting should be addressed, and educational resources provided. Encouraging these patients to reduce the number of cigarettes per day could pay dividends, said Shields, as they may be more apt to try to quit altogether if they find they can successfully reduce the number of cigarettes smoked each day.
Former smokers and those who quit recently (within 30 days) should be evaluated for their risk of relapse. Those deemed at high risk for relapse should be considered for pharmacotherapy and behavioral therapy and offered support resources. In those deemed at low risk for relapse, the success and importance of remaining abstinent should be reinforced, and their risk of relapse should be assessed at every visit.
The guideline does not recommend electronic cigarettes as an aid for smoking cessation because of insufficient evidence to support their use. The same goes for acupuncture, hypnosis, and nutritional supplements. Further, how electronic cigarettes and alternate therapies might interfere with proven methods for quitting is unknown, said Shields.
Shields PG. New NCCN guidelines: smoking cessation for patients with cancer. Presented at: 20th National Comprehensive Cancer Network Annual Conference; March 12-14, 2015; Hollywood, FL.