ACC Cancer Plan
Lung Cancer
Best for last ?
First for last !
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ACC Lung Cancer
Tobacco and Disease: The 5th Annual Lung Cancer
Symposium
November, 2014
http://www.cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo
Tobacco Umbrella
Cancers Other LungOropharynxLarynx Stomach Pancreas…
Stroke Heart attackBronchitis EmphysemaPVD…
US Deaths Next Hour:
Lung Ca Colorectal Breast Prostate02468
101214161820
Tobacco Colorectal Breast Prostate0
10
20
30
40
50US Deaths Next Hour:
Prevention• Adopt tax and price measures to reduce
tobacco consumption• Ban tobacco advertising, promotion and
sponsorship• Create smoke-free work and public spaces• Put prominent health warnings on tobacco
packages• Combat illicit trade in tobacco products
Prevention“It is about an industry, and in particular these defendants, that survives, and profits from selling a highly addictive product which causes diseases that lead to a staggering number of deaths per year, an immeasurable amount of human suffering and economic loss, and a profound burden on our national health-care system. Defendants have known many of these facts for at least 50 years or more.”
Judge Gladys Kessler, Final Order convicting the tobacco industry of racketeering and fraud in U.S. v Phillip Morris
ScreeningEverybody’s
recommending it!
Lung Cancer Screening: Who is doing it?
• over 100 screening programs including:
• NCI Approved cancer centers across the US
• Academic centers• Private non-academic
hospital programs
• for-profit institutions
Lung Screening benefits and risks
Potential Benefits• Has the potential to
detect cancer earlier and save lives
• find more cancers• fewer cancer deaths
(20% decrease)• fewer deaths overall
(6.7%)
Potential harms• invasive procedures in
some participants• false positives can
create worry
Other screening modalities
Not helpful:• Chest Xray• Sputum cytology• bronchoscopy
Potentially helpful• Markers in urine• Volatile organic compounds in
breath• protein markers in blood• genes which demonstrate risk.
Lung cancer screening vs prevention
• Lung cancer is difficult to treat once it occurs.
“an ounce of prevention is worth a pound of cure” B. Franklin
Screening is looking for: the needle in the haystack
• Number needed to treat 320 to save one life
Screening is not a test but a program
Screening program
tobacco cessation
CT Scans
outcomes research
collect demographic
data
collect saliva
443
356
87
Screening
26,722 screened
$8,016,600
What’s wrong with screening
• Very inaccurate – 96% “positive” CTs were not lung cancer
• Very expensive
What’s wrong with screening
• Very inaccurate – 96% “positive” CTs were not lung cancer
• Very expensive • Not clear it applies to AR• Cannot be done the way it was in study• There are better alternatives
Rules of Game NLST
• 55-74 yo with ≥ 30 pack-years• Screen every year for 3 years• 4mm or greater POSITIVE
No change for 2y → NEG
NEJM 2011
California saved $86 billion in health care costs by spending $1.8 billion on tobacco control, a 50:1 return on investment over its first 15 years of funding its tobacco control program.
http://www.cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo
Actionable Screening
• prospective approach to include Enrollment screened patients into a database for
future analysis as to efficacy smoking cessation pre-determined categories of suspicion for
cancer a treatment algorithm that included a group
forum for discussion of difficult cases.
Actionable Screening
• A study of the biological characteristics of lung cancer that would have implications for screening.
Treatment
• Tobacco cessation • Quality of care (access) • Palliative care • Elimination of disparities (access)
Give me your tired, your poor, Your huddled masses, yearning to breath free, The wretched refuse of your teeming shore, Send these, the homeless, tempest tost to me,I lift my lamp beside the golden door.
Statue of Addiction
Inalienable Rights
• The right to bear arms • The right to smoke
Update released May 2008
Sponsored by the U.S. Department of Health and Human Services, Public Heath Service with:
Agency for Healthcare Research and Quality
National Heart, Lung, & Blood Institute National Institute on Drug Abuse Centers for Disease Control and
Prevention National Cancer Institutewww.surgeongeneral.gov/tobacco/
CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE
HANDOUT
Tobacco users expect to be encouraged to quit by health professionals.
Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001).
Barzilai et al. (2001). Prev Med 33:595–599.
Failure to address tobacco use tacitly implies that quitting is not important.
WHY SHOULD CLINICIANS ADDRESS TOBACCO?
The 5 A’s: REVIEW
ASK about tobacco USE
ADVISE tobacco users to QUIT
ASSESS READINESS to make a quit attempt
ASSIST with the QUIT ATTEMPT
ARRANGE FOLLOW-UP care
Faced with change, most people are not ready to act.
Change is a process, not a single step.
Typically, it takes multiple attempts.
HOW CAN I LIVE WITHOUT TOBACCO?
The (DIFFICULT) DECISION to QUIT
HELPING PATIENTS QUIT IS a CLINICIAN’S RESPONSIBILITY
THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT.
TOBACCO USERS DON’T PLAN TO FAIL.
MOST FAIL TO PLAN.
Clinicians have a professional obligation to address tobacco use and can have an important role in helping patients
plan for their quit attempts.
Maintenance
ContemplationAction
Preparation
Pre-contemplation
Relapse*
Not ready to quit
Assess readiness to quit (or to stay quit) at each patient
contact.
For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time.
ASSESSING READINESS to QUIT (cont’d)
Reasons/motivation to quit (or avoid relapse)
Confidence in ability to quit (or avoid relapse)
Triggers for tobacco use What situations lead to temptations to use tobacco? What led to relapse in the past?
Routines/situations associated with tobacco use
STAGE 3: PREPARATIONDiscuss Key Issues
When drinking coffee While driving in the car When bored or stressed While watching television While at a bar with friends
After meals During breaks at work While on the telephone While with specific friends or
family members who use tobacco
“Smoking gets rid of all my stress.”
“I can’t relax without a cigarette.”
There will always be stress in one’s life.
There are many ways to relax without a cigarette.
THE MYTHS
STRESS MANAGEMENT SUGGESTIONS:Deep breathing, shifting focus, taking a break.
Smokers confuse the relief of withdrawal with the feeling of relaxation.
STAGE 3: PREPARATIONDiscuss Key Issues (cont’d)
THE FACTS
Stress-Related Tobacco Use
Routinely identify tobacco users (ASK) Strongly ADVISE patients to quit ASSESS readiness to quit at each contact Tailor intervention messages (ASSIST)
Be a good listener Minimal intervention in absence of time
for more intensive intervention ARRANGE follow-up
Use the referral process, if needed
COMPREHENSIVE COUNSELING: SUMMARY
ASK about tobacco USE
ADVISE tobacco users to QUIT
REFER to other resources
ASSIST
ARRANGE
BRIEF COUNSELING: ASK, ADVISE, REFER
Patient receives assistance, with follow-up counseling
arranged, from other resources such as the
tobacco quitline
Brief interventions have been shown to be effective
In the absence of time or expertise: Ask, advise, and refer to other resources,
such as local group programs or the toll-free quitline1-800-QUIT-NOW
BRIEF COUNSELING: ASK, ADVISE, REFER (cont’d)
This brief intervention can be
achieved in less than 1 minute.
Address tobacco use with all patients.
At a minimum, make a commitment to incorporate brief tobacco interventions as part of routine patient care.
Ask, Advise, and Refer.
MAKE a COMMITMENT…
METHODS for QUITTING
Nonpharmacologic
Pharmacologic
Combination therapy is preferred.
NONPHARMACOLOGIC METHODS
Cold turkey: Just do it!
Unassisted tapering (fading) Reduced frequency of use Lower nicotine cigarettes Special filters or holders
Assisted tapering QuitKey
PHARMACOLOGIC METHODS:
FIRST-LINE THERAPIES
Three general classes of FDA-approved drugs for smoking cessation: Nicotine replacement therapy
Nicotine gum, patch, lozenge, nasal spray, inhaler
Psychotropics Sustained-release bupropion
Partial nicotinic receptor agonist VareniclineThe e-cigarette is not an evidence-based
cessation therapy
Survivorship
• Establishment of an ongoing care plan at end of therapy as part of routine management of every patient with cancer.
• Education of healthcare professionals. • Establish for each patient a primary health care
professional point of contact for the survivor’s care.• Incorporation of survivor input into survivor care
plans • Open channels of communication. Health care
professional to health care professional, health care professional to survivor, and survivor to survivor.
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