Physicians Role in Smoking Cessation Among Bladder Cancer Survivors

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1 Physicians Role in Smoking Cessation Among Bladder Cancer Survivors BCAN August 2014 Jeffrey C. Bassett, MD MPH Kaiser Permanente Southern California

2 Smoking Cessation in Cancer Survivorship Benefits include: Increased overall ± disease-specific survival Decreased morbidity Decreased likelihood of second primary cancer Improved quality of life USDDHS, Executive Summary 2014

3 American Lung Cancer Foundation, 2014

4 Timeline of Benefits of Smoking Cessation Dressler et al, Lancet 2006

5 Smoking Cessation in Cancer Survivorship Rates of successful smoking cessation: Preventative care 1 7% Serious medical diagnosis 10 20% Cancers (tobacco-related) 40 60% Teachable moments Motivation to quit -> Likelihood of success Schnoll RA et al, JCO 2003 Stead LF et al, Cochrane Database Syst Rev 2008

6 Smoking Cessation Clinical Guidelines 5A s Ask Advise Assess Assist Arrange AAR Ask Advise Refer Fiore et al, USDHHS 2008

7 Application of 5A s or AAR Framework to Bladder Cancer Patients?

8 Smoking Cessation Among Bladder Cancer Survivors Teachable moment

9 Teachable Moment of the Bladder Cancer Diagnosis Rates of successful smoking cessation: 31% 48% Context: Lifetime of tobacco use (40+ yrs, 1+ pack/day) Multiple prior failed quit attempts Unassisted quit attempts Fleshner N et al, Cancer 1999 Chen CH et al, BJUI 2007 Bassett JC et al, JCO 2012

10 Smoking Cessation Among Bladder Cancer Survivors Teachable moment Providers role in patient education

11 Survivors Sources of Information on Causes of Bladder Cancer Bassett JC et al, Cancer (in press)

12 Knowledge of the Harms of Tobacco Use Awareness in General Population 25% 36% associate smoking with bladder cancer Lower levels of awareness in: Current smokers Race/ethnic minorities Lower socioeconomic status Nieder AM et al, J Urol 2006 Bjurlin MA et al, J Urol 2012

13 Knowledge of the Harms of Tobacco Use Awareness in Bladder Cancer Survivors 68% 90% associate smoking with bladder cancer Current smokers most aware (90%) 3x greater odds of awareness when urologist was source of information Guzzo TJ et al, Urology 2012 Bassett JC et al, Cancer (in press)

14 Attribution of Cause in Bladder Cancer Survivors Cause of OWN bladder cancer = smoking 84% current smokers 48% former smokers 3x greater odds when urologist source of information Bassett JC et al, Cancer (in press)

15 Attribution of Cause in Cancer Survivors Cancer Survivors: Non-modifiable causes > modifiable Misattribution of cause reduces the patient s motivation to change behaviors Endorsement of tobacco use as the cause is often the impetus for a quit attempt

16 Smoking Cessation Among Bladder Cancer Survivors Teachable moment Providers role in patient education (awareness, attribution of cause) Assistance with smoking cessation

17 Provider Recommendation of Counseling and/or Pharmacotherapy in Quit Attempt Providers Recommendation Counseling AND pharmacotherapy (27%) Counseling OR pharmacotherapy (34%) Neither (39%) Individual provider Urologists (34%) PCP s (57%)

18 Survivor Use of Counseling and/or Pharmacotherapy in Quit Attempt

19 Provider Recommendation Patient Use Strength of recommendation Providers experience with modalities Recommendation provision Access, perceived utility, cost Patient preference 2/3 rd s of cancer survivors not interested Warren GW et al, JOP 2013 Hyland A et al, Amer J Prev Med 2007 Cooley ME et al, Cancer 2011

20 Smoking Cessation Among Bladder Cancer Survivors Teachable moment Providers role in patient education (awareness, attribution of cause) Assistance with smoking cessation Successful smoking cessation

21 Successful Smoking Cessation Method of Quitting: Did not determine success in quit attempt Unassisted > Pharmacotherapy or counseling > Pharmacotherapy and counseling [66% vs. 45% vs. 36%] Smoking cessation paradox: Majority of recent ex-smokers quit with evidenced-based assistance ACS, Cancer Facts & Figures 2003 Shiffman S et al, Amer J Prev Med 2008

22 Correlates of Successful Smoking Cessation Reason for Quit Attempt Bladder cancer diagnosis (OR 11.4, CI ) Timing of quit attempt Within 3 months of diagnosis (92%) 3 months diagnosis (44%)

23 Advice Implications for Providers in the 5A s/aar Framework Goal: maximize the motivation and willingness to make a dedicated quit attempt in patients smoking at bladder cancer diagnosis - Education/information aimed at promoting awareness and attribution of cause - Emphasizing benefits of cessation - Encouraging quit attempt at diagnosis

24 Assist Implications for Providers in the 5A s/aar Framework Goal: ensure that pharmacotherapy and counseling are available for survivors who want assistance in their quit attempt. - Address of barriers - Identification of dedicated resources - Individualized approach

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26 Smoking Cessation and non-mibc 5-year bladder cancer-specific survival > 95% Disease-specific benefits: Decreased risk of secondary malignancy - 65,980 (12%) of bladder cancer survivors diagnosed with 2 nd tobacco-related 1 tumor Tobacco-related morbidity and mortality Altekruse SF et al, SEER Cancer Statistics Review, Wilson RT et al, SEER Cancer Registries,

27 Muscle-invasive Bladder Cancer Treatment options: Radical cystectomy Bladder preservation protocols - endoscopic resection, chemotherapy, XRT (± salvage cystectomy) Cystectomy 90-day complication rate: Overall 50 65% Readmission 20 30% Mortality 1 3%

28 Muscle-invasive Bladder Cancer Standardized reporting (Clavien-Dindo) 90-day complication rate (64%) Gastrointestinal (30%) Infectious (25%) Wound-related (15%) Cardiac (11%) Pulmonary (9%) Shabsigh A et al, Euro Urol 2009

29 Muscle-Invasive Bladder Cancer Shabsigh A et al, Euro Urol 2009

30 Muscle-Invasive Bladder Cancer Shabsigh A et al, Euro Urol 2009

31 Peri-operative Smoking Complications Complications Associated with Tobacco Use: Wound infections Anastomotic leaks Pneumonia/Prolonged intubation MI/Cardiac arrest Stroke Sepsis/Shock Khullar D and Maa J, J Am Coll Surg 2012

32 Peri-operative Smoking Cessation RCT Evidence: Moller AM et al, Lancet patients (cholecystectomy, hernia repair, hip) 21% vs 41% complication rate Lindstrom D et al, Ann Surg patients (hip or knee replacement) 18% vs 52% complication rate

33 Peri-operative Smoking Cessation Myers KHP et al, Arch Intern Med 2011