The science is clear: Cancer patients who quit smoking fare much better than those who don’t. Quitters respond better to treatment and are less likely to see their disease come back or develop a new cancer, and they have a lower risk of other serious conditions such as heart disease. Quitting is hard, but people who participate in evidence-based tobacco-treatment programs are three times more likely to succeed in kicking the habit.
Still, despite the proven benefits of quitting, most cancer patients who smoke never receive treatment for their tobacco use.
A large-scale, multicenter trial led by researchers at Washington University in St. Louis aims to reduce the burden of cancer by getting more patients the support they need to quit smoking. The trial — a four-year study to be conducted at 72 cancer centers across eight states, including Siteman Cancer Center, based at Barnes-Jewish Hospital and WashU Medicine — will test different clinic-based approaches to connecting cancer patients to tobacco treatment, with a goal of developing evidence-based recommendations on how to choose, implement and sustain an effective tobacco-treatment strategy at a cancer clinic.
“Even though smoking cessation is part of the standard of care, six out of seven patients with cancer who smoke are not getting any tobacco treatment, so they continue to smoke, and eventually they die early,” said Li-Shiun Chen, MD, MPH, ScD, a professor of psychiatry at WashU Medicine and one of three principal investigators on the trial. “That’s a big missed opportunity. We already know an important way to reduce cancer deaths, and we’re not implementing it.”
A previous effort to integrate tobacco cessation into cancer care nationwide revealed sobering results. In 2017, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative, an ambitious plan to roll out tobacco-treatment programs at 52 NCI-designated Comprehensive Cancer Centers nationwide. A five-year analysis revealed that the centers had succeeded in connecting only 15% of their cancer patients with such care, with huge variation in connection rates across centers.
“Scaling up is not a simple thing,” said Ross Brownson, PhD, the Steven H. and Susan U. Lipstein Professor at WashU Public Health and one of the principal investigators. “Many of these centers used similar strategies, but the results were varied. We need to understand why a strategy that was effective for one center didn’t work at another one, and what alternative strategy would be more effective.”
That need drove Chen, Brownson and Alex Ramsey, PhD — an associate professor of psychiatry at WashU Medicine and a third principal investigator on the trial — to propose the Implementation Science to Scale and Sustain Tobacco Treatment Leveraging a Point of Care Paradigm and Health Information Technology (IMPACT) trial, co-led by the three in collaboration with experts and colleagues at the University of Pennsylvania, Vanderbilt University Medical Center and the St. Louis VA Medical Center.
The trial, which will be implemented at cancer clinics affiliated with the four hub sites, aims to determine how to match strategy to clinic, taking into consideration factors such as the size of a clinic, the barriers to receiving care faced by its patients, and the institutional support and resources available. The WashU team is implementing the trial at clinics affiliated with Siteman. Chen serves as director of the Tobacco Treatment Program at Siteman, and she, Brownson and Ramsey are all research members at Siteman.
The trial is supported primarily by the NCI, which has committed $1.6 million, with another expected $5.3 million dependent upon successful completion of the first phase. Siteman has committed an additional $600,000. It is one of four projects in the NCI’s Scaling-up and Maintaining Evidence-based Interventions to Maximize Impact on Cancer (SUMMIT) initiative, a major investment in improving cancer prevention and control by studying how to implement proven interventions in real-world settings.
As part of the trial, each clinic will be randomized to one of four strategies: usual care, referral to a specialist, point of care, or combined referral and point of care. The referral strategy is the most common way of getting patients into tobacco care: The oncologist asks about smoking during a regular visit and refers those who answer yes to a tobacco-treatment specialist. The patient then makes an appointment to meet the specialist at a separate visit. The strategy can work well when a cancer center is able to fund enough tobacco specialists, and patients have the time, resources and willingness to add more appointments to their calendars.
The point-of-care model was developed by Chen and colleagues at Siteman during a time when no tobacco-treatment specialists were on staff. In this model, all hands are on deck: Medical assistants, staff nurses, and nurse practitioners conduct the tobacco-use assessment, provide brief advice to quit smoking and queue cessation medication orders for the clinician to prescribe. They also refer patients to free phone, text or app-based cessation services. In a recent study, Chen and colleagues showed that a point-of-care approach can be very effective at helping cancer patients quit smoking and improving outcomes.
The record of the Cancer Center Cessation Initiative suggests that many of the clinics may not initially succeed with the strategy they are assigned. Those that are unable to connect at least 15% of eligible patients to tobacco treatment after 18 months will be offered the options of continuing the current strategy, if more time is thought to be helpful; trying a different strategy; or modifying their strategy to include personalized tobacco-treatment plans based on each patient’s unique genetic, clinical and environmental factors.
In those clinics that do succeed, the focus will shift to sustainability. New clinical practices, even successful ones, are at risk of being abandoned when funding ends or priorities change. To minimize this risk, clinics will be provided either general sustainability support, or clinic-specific support based on data from the Clinical Sustainability Assessment Tool. The validated tool — developed at WashU Public Health’s Center for Public Health Systems Science — provides a systematic way to assess the factors that promote sustainability of clinical practices.
“Even when we know what treatments or prevention tools work, we don’t know enough about how we can implement them quickly, scale them up more widely or sustain them long enough,” Ramsey said. “The ultimate goal is to make sure that every single cancer patient who smokes is engaged with treatment, but the route to get there is going to be different for each clinic. We need to figure out which strategies will work best in which context, so we can use the evidence-based tools we already have to improve people’s health.”
Writer
Tamara Schneider, MPH, PhD, is the senior science writer and assistant director of communications for WashU School of Public Health. She holds a bachelor’s degree in molecular biophysics & biochemistry and in sociology from Yale University, a master’s in public health from the University of California, Berkeley, and a PhD in biomedical science from the University of California, San Diego.