1. Susman, Ed

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SAN FRANCISCO-When head and neck cancer patients are diagnosed with advanced disease, the majority of them will immediately stop smoking-but nevertheless, 280 days after getting the bad news that they have cancer, 41 percent of the patients are still lighting up, researchers said (Abstract 184).

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The inability to stop smoking may also be linked to depression, said Harsha Vardhan Poola, MD, a fellow in Hematology/Oncology at the John H. Stroger, Jr. Hospital of Cook County in Chicago, in his poster presentation at the ASCO Cancer Survivorship Symposium.


"One of the most important factors for patients to quit was the diagnosis of head and neck cancer," Poola told OT. "We found that 50 percent of patients diagnosed with stage 3 or stage 4 cancer quit at that diagnosis. But the early stage cancer patients continued to smoke, even through treatment and afterward.


"We had 76.5 percent of the 39 patients in the study smoking when they were diagnosed with advanced cancer. After treatment and 280 days later, 41 percent of those patients were still smoking, so we had about a 50 percent decline in smoking, which was statistically significant (P<0.001)," he said. "We also had high rates of depression, which is not uncommon in head and neck cancer patients. Although smoking rates on diagnosis in our cohort is comparable to literature, our cohort had higher rates of continued smoking and depression."


There was a trend toward depression among smokers (62%) compared to non-smokers (55%) among the patients with stage 3 and 4 disease, he said, but that difference was not statistically significant.

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"We would like to see if we treat patients-especially African-American patients-for depression whether that would make a difference in their smoking habits," he said. He also suggested researchers may explore if smoking cessation may be able to prevent depression, especially in underserved communities.


"Continued smoking among head and neck cancer patients is associated with poor prognosis," he noted. "These patients experience the highest rates of depressive symptoms of all oncology patients.


"Larger studies are needed to address the effects of continued smoking and depression in the quality of life of minority populations," Poola said. "We are continuing to expand our data with the goal of screening all head and neck cancer patients and to eventually start a smoking cessation program in the ear, nose, and throat/head and neck cancer clinic."


Smoking Prevention

The overarching problem is nicotine and its addictive effects on smokers, said Dennis H. Kraus, MD, Director of the Center for Head & Neck Oncology at New York Head & Neck Institute, Northwell Health Cancer Institute at Lenox Hill Hospital, New York City.


"Tobacco is an addiction. For anyone who is depressed, the effects of addiction are additive if not exponential," Kraus told OT in commenting on the study. "I don't believe it is any easier or more difficult based on an underlying disease. If anything, folks undergoing radiation-based therapy often describe how bad the tobacco tastes during that therapy."


He said getting people to quit smoking is not just saying no. "Quitting is best facilitated by a host of factors, including a motivated patient, coupled with a patient-centric support system," Kraus said. "Literature shows that patients who receive services such as counseling, positive reinforcement, and tobacco replacement such as patches are likely to have the best outcome. A patient-centric support system can mean the difference between success and failure."


Kraus said the best way to stop patients from smoking is to prevent them from becoming addicted in the first place. "For starters, we need to prevent addiction," he said. "We don't provide minors and young impressionable adults access to needles and heroin, and then ask them to quit."


Study Stats

In Poola's study, the patients' mean age at diagnosis was 55.84 years. Eighty-two percent of the patients with stage 3 and stage 4 head and neck cancer who smoked were men. Seventy-four percent of the entire cohort had stage 4 disease at diagnosis. Forty-six percent of the smokers were African-American, while 36 percent were Caucasian. He said the smoking patterns and depression in the prospective cohort of head and neck cancer patients was evaluated by through surveys and chart review.


Depression was assessed using the Patient Health Questionnaire (PHQ-9). Head and neck cancer patients were stratified as non-smokers; ex-smokers-defined as those who had quit at least six months prior to their assessment; recent smokers-those who had quit for less than 6 months; and current smokers-individuals who had smoked within the last week. The patients' electronic medical records were reviewed for sociodemographic variables, cancer stage, date of diagnosis, and modality of treatment. The cohort was followed through July 2015 to assess for recurrence of disease and survival.


Poola noted persistence of smoking after diagnosis was seen significantly more in the Caucasian population compared to the rest of the ethnicities (P=0.038). Complete response to treatment was seen in 82 percent of the patients and recurrence occurred in 20.5 percent of the patients.