Nick Mulcahy

March 19, 2015

HOLLYWOOD, Florida — The "need to do better" is the inspiration for a new smoking-cessation guideline for cancer patients from the National Comprehensive Cancer Network (NCCN), according to one of its authors.

There is an absence of "systematic and consistent mechanisms for fostering cessation" in cancer patients in healthcare institutions in the United States, explained Peter G. Shields, MD, from the Ohio State University Comprehensive Cancer Center in Columbus, who chairs the panel of experts who wrote the guideline.

Into that breach comes the NCCN and its trademark guidelines, he said here at the 20th Annual Conference.

The need is great, said Dr Shields. An estimated 20% to 30% of cancer patients smoke.

"In my practice, among my lung cancer patients, probably 50% are active smokers," he said in a press statement.

The new NCCN guideline establishes standards of care and fills a gap that exists in current guidelines, he said.

There are a host of benefits to quitting. Dr Shields listed the effects that have the strongest evidence, citing the 2014 Surgeon General's Report. Most notably for cancer patients, cessation improves prognosis, he said. Not quitting increases the risk for death and primary secondary cancers.

Less authoritative evidence indicates that smoking increases the risk for second cancers and is associated with poorer responses to treatment and increased treatment-related toxicity.

"While smoking cessation has always been a relevant and important topic in the field of cancer care, the development of the newly published NCCN guideline for smoking cessation was, in part, promoted by information that was included in the 2014 Surgeon General's Report," according to an NCCN statement.

In addition, the American Association for Cancer Research and several of the NCCN member institutions requested that the NCCN prioritize publication of the new smoking-cessation guideline because existing smoking-cessation guidelines focusing specifically on individuals with cancer were not adequate, the organization said.

Cancer Diagnosis Is a "Teachable Moment"

Despite the health benefits of cessation, only about 50% of oncologists advise patients to quit, even though a cancer diagnosis is a "teachable moment" for the patient, Dr Shields explained.

But do clinicians get paid for this counseling? "Policies regarding reimbursement for smoking-cessation counseling will vary by payer," the NCCN statement said.

One of the major messages of the guideline is that "there are established methods for helping a patient quit," he noted. But clinicians must first identify where patients are on a continuum of tobacco use.

There are three broad categories: never smokers, current smokers, and former smokers.

Among former smokers (including those who have not smoked in the previous 30 days), clinicians should stratify patients by risk for relapse.

High risk for relapse is indicated by one or more of the following criteria: intense cravings, elevated stress, cohabitation with a smoker, having quit for less than 1 year, current use of a cessation treatment, and drug use (including marijuana).

Patients at high risk for relapse can be offered a variety of interventions, including pharmacotherapy and behavioral therapy.

But a patient must be "ready to quit" and a quit date must be established, Dr Shields explained, relaying the guidelines. Those who are not ready should be offered nicotine replacement therapy (NRT) or varenicline (Chantix, Pfizer), as well as information about the benefits of cessation.

Tools to Use

E-cigarettes and "complementary" approaches, such as acupuncture, hypnosis, and nutritional supplements, are not recommended because of the lack of sufficient evidence of their efficacy, he said.

However, pharmacotherapy is "effective and recommended," said Dr Shields.

There are three lines of pharmacotherapy options.

In the first line, combination NRT is recommended (nicotine patch plus a short-acting lozenge, gum, inhaler, or nasal spray). The other option is varenicline.

In the second line, two combinations are suggested: either varenicline plus NRT or bupropion plus NRT.

Finally, in the third-line, there are three options: varenicline plus bupropion with or without NRT; nortriptyline (a tricyclic antidepressant); and clonidine, an alpha-2 adrenergic receptor agonist used for hypertension.

There are some drug warnings that accompany pharmacotherapy. The use of varenicline and bupropion requires that the patient be monitored for the development or worsening of psychiatric symptoms. Bupropion is contraindicated for patients with seizure risks, in those taking MOA inhibitors or tamoxifen, and in those with closed-angle glaucoma.

Behavioral therapy, one of the cornerstones of quitting, includes helping patients identify "risky" situations (e.g., stress, alcohol, other smokers, and other triggers for urges). Patients will need to develop "coping" skills to avoid those risks, said Dr Shields.

Notably, pharmacotherapy without behavioral therapy is less effective, he said.

More intensive behavioral therapy, with a dose–response effect, is preferred over brief therapy. Also, counseling can be in-person, by phone, or in a group. Behavioral therapy is tailored on the basis of a patient's nicotine dependence and history of quitting attempts.

A multimodal approach "is the most successful strategy to promote quitting. This includes evidence-based pharmacologic interventions, behavioral counseling, and follow-up to ensure ongoing compliance," according to the NCCN statement.

Dr Shields has financial relationships with various law firms for chemical exposure cases.

NCCN 20th Annual Conference. Presented March 13, 2015.

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