You are listening to a podcast from cancer.net. This cancer information website is produced by the American Society of Clinical Oncology known as ASCO, the world’s leading professional organization for doctors that care for people with cancer.  In today’s podcast we’ll discuss the benefits of stopping tobacco use, also called tobacco cessation, after a cancer diagnosis.  This podcast will be lead by Dr. Graham Warren, who is a radiation oncologist and a clinical director of the Just Breathe Tobacco Assessment and Cessation Program at Roswell Centre Institute in Buffalo, New York. He also serves on the tobacco task force for the American association for cancer research and is a member of the Committee for Cancer and Leukemia Group B Alliance Cooperative Clinical Trials Program sponsored by the National Cancer Institute. ASCO would like to thank Dr. Warren for providing this summary for patients on how to stop tobacco use.

Hello, my name is Graham Warren and I’m a Radiation Oncologist at Roswell Park Cancer Institute and also a cancer researcher who looks at the effects of tobacco and tobacco use on outcomes in cancer patients. Today I was going to talk about the effects of tobacco in cancer patients mostly as related to cancer treatment outcomes and how cancer treatments such as chemotherapy, radiation or even surgery may change based on how a patient uses tobacco. Most people know that tobacco use is highly associated with the development of several different forms of cancer and the unfortunate nature about this is that not only does tobacco increase the risk of cancer but it also increases the risk of heart disease, stroke and other diseases that end up leading to about a 13 to 14 year loss of life in people who smoke. So it unfortunately shortens life span for a variety of different reasons and what most people don’t realize is that even though tobacco use is associated with a significantly increased risk of developing cancer, it also is associated with significant decreases in the effectiveness of cancer treatment.  

There have been a number of studies who have taken a look at tobacco use in different cancer treatment populations, and what we know is that people who continue to use tobacco during cancer treatment have a decreased response to chemotherapy and radiation. The net effect of this is that if a person continues to use tobacco during cancer treatment then there’s an increased risk of the tumor not shrinking as well or the tumor coming back. And what would happen is that if the tumor doesn’t shrink down very well and does not go away at the end of chemotherapy or radiation then there’s a very high chance that the tumor will either come back or metastasize to other spots in the body. Not only that, your best chance to try and cure cancer is your first cancer treatment which means  the first time you get chemotherapy or radiation, or your first line  treatment, is the best chance to try to cure or get rid of a cancer. And unfortunately most of the second line treatments and third line treatments don’t work nearly as well as first line treatment. So if a person uses tobacco during their first line treatment and their treatment doesn’t work as well then they really burn a lot of bridges for the possibility of controlling cancer down the road.  And in order to try and see if we can prevent some of these effects there is a couple of different things that we can do. One of the most important things that a person can do, and a clinician can do is to recognize that tobacco is an extremely important part of standard cancer care. A lot of times primary care physicians, family doctors, internal medicine physicians will ask patients about tobacco use and try and get a patient to quit using tobacco. A lot of times surgeons will ask patients to stop using tobacco before surgery. But unfortunately a lot times people think that once they’re diagnosed with cancer tobacco use is irrelevant and that it’s too late. That’s not the case, in reality tobacco use is something that a person can quit at any time and will benefit from it.  

In the case of a cancer patient stopping tobacco use immediately when they are diagnosed will increase the chances that they will respond to chemotherapy or radiation, but it also increases the possibility that the tumors won’t come back after surgery. It also decreases the risks associated with surgery such as pulmonary infections, wound infections, ICU days or hospitalizations. So the toxicity from treatment is also much better if a person doesn’t smoke or use tobacco.  So the net message and the most important message from this is that even when a patient is diagnosed with cancer it’s never too late to quit, it is still a very good idea for a patient to quit using tobacco and try to stop immediately. Now one might think that tobacco is just smoking and most all of the studies smoking represents 80 to 85 even 95 percent of total tobacco use in the United States. But unfortunately other forms of non-combustible tobacco may be just as bad, but we just don’t have enough data on it to show what cigars or  pipe tobacco or other forms of tobacco can do  to cancer treatment. My recommendations would be that all forms of tobacco should be avoided during cancer treatment.  Smoking is the most relevant because it affects the most patients but any kind of tobacco may potentially affect cancer treatment and outcomes.  Not only that tobacco, other than smoking, is also associated with an increased risk of maintaining an addictive habit.  The more a person continues to expose themselves to tobacco or nicotine or other tobacco related products the longer the chances are that they are going to remain addicted to tobacco as a substance. So it’s just going to be harder to quit.  So the long and short of it is that its important for patients to try and stop all forms of tobacco use as soon as possible when they are diagnosed with cancer.

Now we talked about the possibility of improving cancer treatment and control and survival. Stopping tobacco can also significantly improve your risk of heart disease or stroke or pulmonary disease, but you’ve got to remember when a person is diagnosed with cancer a lot of the times they hear the word cancer and they forget about everything else that is going on in their life. But every cancer patient has a heart, lungs, brain; all the normal tissues in the body. All of those normal tissues don’t respond well to tobacco smoke. So not only does stopping smoking lead improve the chances of getting a better cancer treatment but it also improves the chances that a patient  will have improved cardiovascular function, improved pulmonary function, decreased risk of a stroke and other diseases associated with tobacco use.  So stopping tobacco use benefits not only cancer care but also the remainder of the patient. Now one of the things in cancer patients that makes it difficult for cancer patients to quit is not only the addictive nature of tobacco and nicotine but its also the new diagnosis of cancer. Many people who smoke have different stressors in their life and smoking helps them feel better, helps them relax, helps take the edge off of their day. When a person is diagnosed with cancer a lot of the times it is a huge stress and though there’s not a lot of data that has looked at this, in my experience a lot of cancer patients continue to smoke specifically because it helps them feel a little bit better during treatment. 

Now I treat patients even if they can’t stop smoking but the best chance, the best chance, that they’re going to give themselves to get rid of cancer and survive and have a better quality of life is if they stop smoking.  So I try and inform them that no matter how hard it is to quit it is the best decision that they can make and that’s one of the important messages that we can have as clinicians.  A lot of times cancer patients when they are diagnosed they don’t have any control over the treatment of their disease. They don’t have any control over their surgery or their chemotherapy or their radiation, this is all administered by other doctors or health care professionals. And a lot of times the cancer patient may feel like their life is just out of control with all these new treatments. But in reality one of the things that the patient can do that may be of an enormous benefit is that they are the ones that can choose to stop smoking. They are really the only ones that have the control over their ability to stop smoking. So this is something specifically that actually empowers patients, they can do something proactively themselves to help their cancer treatment and their help overall outcomes for survival for cancer and other diseases. So it can be a very empowering activity by cancer patients by stopping smoking and I try and promote this as much as I can. 

Now there are several resources to try and help people quit, there‘s quit lines and there’s institutional cessation services at some cancer centres.  Also a lot of times primary care physicians are extremely good resources, the overwhelming majority of primary care physicians are very devoted to trying to get people to stop smoking. They’ve worked with people for years to try to quit smoking and I would bet that most cancer patients have heard from their primary care docs numerous times that “You need to quit smoking”. So their primary care doctor can also be a big resource to help. One of the other things that can be a big resource to help is their family. It’s very hard to quit smoking if your spouse smokes or if your father or mother or brother smokes and they live in the house with you. So try and get your friends, your buddies and family members to stop smoking can also be a big resource to help you quit. So there are several resources to try and help, and it just depends on the particular situation the person is in, what their family environment is like and what their institution is like and the resources that they would have available. 

One of the resources that unfortunately is not available as much as I would like is a strong resource by cancer clinicians to provide strong cessation support. There are some clinicians that do an excellent job of providing cessation support for their cancer patients. But unfortunately this is something we are working on very hard nationally is to try and increase the awareness that tobacco use in cancer patients is extremely important and needs  to be a standard part of clinical care for all cancer. So one of the things cancer patients can do is to realize that tobacco is important for their cancer care and it is important for trying to get a cure from cancer and it still is important to try and help their heart and their lungs and the rest of their body work after a cancer diagnosis. One of the things they can do is to tell their clinicians about it, make sure their clinicians know that tobacco use is important and ask their cancer care clinicians how they can stop tobacco use and if there’s anything they can do to try and help. This could be one of the best messages that we could make nation-wide is to realize that tobacco use is something that is extremely important for cancer care as a whole and the more clinicians we can get involved and the more health care providers, nurses, physicians, physician assistants, even social workers, and  people at the administrative level can help tremendously with providing resources for people to stop smoking. 

So I hope that some of this information has persuaded people to realize that tobacco use is very important even in cancer patients and that stopping tobacco use can be one of the best decisions that a cancer patient can make to improve their overall health for both cancer and for other diseases in their body.

Thank you Dr. Warren. More information on stopping tobacco use can be found at www.cancer.net or by talking with your healthcare team. Cancer.net is supported by the Conquer Cancer Foundation which is working to create a world free of the fear of cancer by funding breakthrough research, sharing knowledge with physicians and patients world-wide and supporting initiatives so that all people have access to high quality cancer care. Thank you for listening to this cancer.net podcast