A unique tobacco cessation service for cancer patients at Roswell Park Cancer Institute: Acceptance, participation and impact
Amato, Katharine Ann
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Problem under Investigation: Smoking cessation amongst cancer patients is often thought of as less important because the patient has already developed cancer. However, increasing evidence suggests that continued tobacco use during cancer treatment reduces the effectiveness of treatment, increases negative side effects of the treatment, decreases the quality of life, and increases the risk for tumor recurrence, second primary tumors or death. To date, limited research has been conducted to improve cessation efforts among cancer patients or measure the impact of smoking cessation on survival. Most studies rely on an opt-in randomized control design impacting a limited number of patients or on retrospective chart review with smoking status collected in an inconsistent manner. More data are needed to better understand the impact of smoking cessation among cancer patients. Roswell Park Cancer Institute Tobacco Assessment and Cessation Service: Patients seen in all clinics at Roswell Park Cancer Institute (RPCI), including the thoracic clinic, have tobacco use assessed every thirty days; an automatic electronic referral is generated to a free opt-out telephone based cessation support service for all patients who indicate current or recent (last 30 days) tobacco use, which offers up to eight cessation support telephone calls. Specific Aims: The goal of Specific Aim 1 is to describe the reach and potential impact of the RPCI Tobacco Assessment and Cessation Service (TACS) by describing the patients who participate in the service and by examining the initial quit rates of participants in the current program. The goal of Specific Aim 2 is to conduct a 3-month follow-up of all participants to determine their self-reported quit rates for the previous seven days, as well as patient satisfaction with the RPCI TACS. The goal of Specific Aim 3 is to examine survival rates with relation to smoking status for lung cancer patients referred to the RPCI TACS. Research Methodology: The majority of patient information was extracted from the electronic medical records, finance records, and tumor registry at RPCI for all three specific aims. Mailed surveys, along with follow-up telephone interviews for non-responders or to obtain any missing information, were conducted to obtain self-reported quit status 3-months after the first contact by the RPCI TACS for Specific Aim 2. Univariate and multivariate statistics were used to examine the factors associated with and predictors of quit rates at 1-month and 3-months for Specific Aims 1 and 2. Stratification by patient gender, tobacco use status at referral, disease characteristics, and other health behaviors were explored. Specific Aim 3 was evaluated using univariate and survival analysis statistical methods to determine predictors of other health outcomes associated with thoracic cancer. Results: For Specific Aim 1, 78.3% of 942 thoracic clinic patients referred to RPCI TACS were successfully contacted and participated in the first call; among those who participated in the first call and were called for a follow-up, 88.7% (401/452) participated. Among current users at referral, 26.0% (89/342) reported cessation at follow-up. Among those contacted twice, lung cancer patients were statistically more likely to quit at follow-up compared to other thoracic clinic patients (OR=1.78; 95% CI: 1.02-3.11) and thoracic clinic patients in poorer health (as indicated by a higher ECOG performance score (≥1)) were less likely to quit at follow-up compared to healthier patients (ECOG PS=0; OR=0.43; 95% CI: 0.34-0.77), while controlling for other demographic, health and disease characteristics. For Specific Aim 2, 55.5% (142/256) reported being smoke-free for at least the previous 24 hours at the 3-month follow-up; 86.4% reported being very or mostly satisfied with the service they received from RPCI TACS. For Specific Aim 3, after controlling for age, pack-year history, sex, performance status, time between diagnosis and last contact, tumor histology and clinical stage; a statistically significant increase in survival was associated with quitting compared to continued tobacco use at last contact (HR=1.79; 95% CI: 1.14-2.82), with a median 9 month improvement in overall survival. Conclusions: Thoracic cancer clinic patients are receptive to a free opt-out telephone-based cessation service following a cancer diagnosis, negative biopsy, or participation in a high risk screening program, as indicated by the high participation rates. Patients are interested in participating, are making efforts to quit, and are satisfied with the service they have received. Lung cancer patients who quit show improved survival compared to those who continued using tobacco. Potential Significance: This unique RPCI Tobacco Assessment and Cessation Program will benefit from evaluation and improvement. Results from this dissertation can be applied to making future improvements within RPCI TACS (i.e. by determining optimal timing, frequency, duration, and framing of cessation support messages), can guide the development of a framework to evaluate and improve the cessation service for all other cancer sites, and can offer an example for other comprehensive cancer centers intending to implement a similar program with mandatory tobacco use assessments and automatic referrals to an opt-out cessation support service.
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