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NCCN Issues New Smoking-Cessation Guidelines for Patients with Cancer

TOP - August 2015, Vol 8, No 3

Hollywood, FL—A new clinical guideline for smoking cessation in patients with cancer encourages the use of evidence-based pharmacotherapy, behavioral therapy, and close follow-up with retreatment if needed, said Peter G. Shields, MD, Deputy Director, Comprehensive Cancer Center, James Cancer Hospital, Columbus, OH, at the 2015 National Comprehensive Cancer Network (NCCN) conference.

According to the American Association for Cancer Research Task Force on Tobacco, “Virtually no institutions reported systematic and consistent mechanisms for fostering cessation,” Dr Shields said.

Many patients with cancer still smoke, and those who do have worse outcomes when treated for their cancer, Dr Shields said, citing at least 1 study on the negative influence of smoking on the efficacy of radiation therapy in head and neck cancer.

Dr Shields noted that patients with cancer who smoke are typically more dependent on nicotine and probably have a history of unsuccessful attempts to quit. According to the NCCN guidelines, the most effective approach to smoking cessation 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 Dr Shields. Behavioral therapy can take the form of individual in-person counseling, phone counseling, or group counseling.

Smoking status should be documented and should be updated at regular ­intervals. Oncologists should discuss smoking relapse and provide guidance for patients.

Smoking relapse may warrant a change in therapy. “Sometimes smokers require repeated quit attempts with the same therapies, as smoking slips and relapses are common,” Dr Shields said.

Smoking-Cessation Therapy

In addition to NRT, varenicline (Chantix) is considered a first-line pharmacologic treatment. Second-line options include varenicline plus NRT and bupropion (Zyban) plus NRT. Third-line options include varenicline plus bupropion with or without NRT, the tricyclic antidepressant nortriptyline (Pamelor), and the alpha-2 adrenergic receptor agonist clonidine (Catapres).

Bupropion is contraindicated in patients at risk for seizures, and users of varenicline and bupropion should be monitored for the worsening of serious neuropsychiatric issues.

Evaluate Smoking Status

The guideline calls for an evaluation of patients’ current smoking status, and “prioritizes those likely to relapse,” said Dr Shields. “Current smokers and those smoking within 30 days are treated the same.” These patients should have their readiness to quit assessed. The patients who are ready to quit should be given a personalized quit plan that includes the smoking-cessation therapies noted above.

Patients who are not ready to quit should be counseled on the risks of smoking and the benefits of quitting. Barriers to quitting should also be addressed, and educational resources provided. Encouraging these patients to reduce the number of daily cigarettes could pay dividends, said Dr Shields, because they may be more apt to try to quit altogether if they can successfully reduce the number of cigarettes smoked each day.

Risk for Smoking Relapse
Former smokers and those who quit recently (within 30 days) should be evaluated for their risk for relapse. Patients at high risk for smoking relapse should be considered for pharmacotherapy and behavioral therapy and be offered support resources. In patients deemed to be at low risk for relapse, the success and importance of remaining abstinent should be reinforced, and their risk for relapse reassessed.

The guideline does not recommend electronic cigarettes as an aid for smoking cessation, because of insufficient evidence to support their use.

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