Quitting smoking after cancer diagnosis can add years to patient lives

Quitting smoking within six months after a cancer diagnosis adds an average of two years to a patient's life.

With this information in hand, all cancer centers have an obligation to offer evidence-based smoking cessation to all patients, said Graham Warren, M.D., Ph.D., vice-chair for Research in the Department of Radiation Medicine. He's also the Mary Gilbreth Endowed Chair of Oncology, an MUSC Hollings Cancer Center researcher and senior author of a new paper that demonstrates a broad survival benefit of using evidence-based smoking cessation to help patients quit smoking as soon as possible after a cancer diagnosis.

This is a survival benefit that we can achieve now. It isn't something that we need to wait 10 years for trial results. If we miss patients now, well, they've missed the benefit that they would gain from it. So there's an urgent responsibility to make this work. It is important to make sure that we give everyone evidence-based care specifically to help them improve survival. This isn't an optional thing."

Graham Warren, M.D., Ph.D., Vice-Chair for Research, Department of Radiation Medicine, MUSC

It's well known that smoking after a cancer diagnosis decreases the effectiveness of treatment and increases the likelihood of certain side effects or complications. And some previous papers have looked at the survival benefit of quitting smoking in specific subgroups of cancer patients, like lung cancer patients.

In this paper, published in JAMA Oncology, Warren and his collaborators at MD Anderson Cancer Center were able to use data from the Tobacco Research and Treatment Program (TRTP) at MD Anderson to look at long term survival across more than 4,500 patients with a wide variety of cancers.

The records from this program were valuable because they regularly note a patient's current smoking status and use of a structured evidence-based tobacco treatment program. Too often, Warren said, cancer centers ask about a patient's smoking status at diagnosis but don't follow up throughout treatment to update the electronic health record.

With the detailed records from the TRTP, the researchers were able to subdivide patients into three groups: those who stopped smoking within six months of diagnosis, those who stopped between six months and five years after diagnosis and those who stopped more than five years after diagnosis. Quitting smoking after a cancer diagnosis improved survival across cancer as a whole, with the largest benefit among patients who quit within six months following diagnosis.

David Marshall, M.D., chair of Radiation Medicine and medical director of the Clinical Trials Office at Hollings, said the clear benefit of smoking cessation after diagnosis across all types of cancer places particular emphasis on the need to improve clinical treatment approaches for all patients. Marshall's expertise is in prostate cancer and clinical trials, and he noted the impact of smoking on outcomes in prostate cancer.

"Most prostate cancer patients don't die of prostate cancer. It is often smoking-related conditions that contribute to patient deaths," he said.

Quitting smoking even among patients with non-tobacco related cancers can be one of the biggest contributors to improving overall survival.

Warren said these data likely represent the new gold standard cementing the survival benefit for supporting smoking cessation programs at cancer centers. Unfortunately, he said, while up to 90% of patients are asked about smoking, only about 40% of centers provide smoking cessation assistance.

"This isn't like developing a new targeted agent. You don't need new protocols or to buy new drugs," he said. "If you understand the importance of this, you can start doing it this afternoon. The evidence is there. The treatments are there. It's just a matter of getting clinicians to put it into practice and patients receiving evidence-based treatment."

Raymond N. DuBois, M.D., Ph.D., director of MUSC Hollings Cancer Center, noted the significance for all types of cancer.

"This research shows in a very clear and straightforward manner what clinicians have often observed – that their patients who continue to smoke fare worse than those who are able to stop smoking," DuBois said.

"This is a significant finding for people dealing with any type of cancer diagnosis, not just lung cancer, and for their doctors. Also, we have known that continued smoking after a cancer diagnosis weakens the immune system, making it harder for the body to fight off cancer cells."

K. Michael Cummings, Ph.D., a colleague at Hollings with an extensive tobacco research record who has collaborated with Warren on other projects but not this paper, said the paper shows the clinical necessity of offering smoking cessation programs.

"Patients and family members need to be informed of the benefits of stopping smoking," he said. "Additionally, patients who smoke need to be given real help to stop smoking, recognizing that getting off cigarettes is not easy to do. Cigarette addiction is a chronic relapsing disorder so one-off interventions for patients are inadequate."

Tobacco treatment program at MUSC Health

MUSC's tobacco treatment program, established in 2014, offers the type of evidence-based intervention that can help people to stop smoking.

Patients are assigned to a trained smoking cessation counselor, who can assist with pharmacotherapy to deal with the physical need for nicotine and with behavioral counseling to deal with the mental load. They meet regularly, usually by telephone, so the counselors can help the patients to stay on track.

Importantly, this work touches every cancer patient who smokes.

"Thanks to the work of Dr. Warren and others, since 2021 Hollings Cancer Center has implemented an opt-out tobacco treatment program where every patient seen in a Hollings outpatient oncology clinic (now up to 52 clinics across South Carolina) is routinely screened to assess smoking status and automatically refers those who currently smoke to our telehealth-pharmacy assessed tobacco treatment program where patients can receive behavioral support and stop smoking medications to assist them in their journey to get off cigarettes," Cummings said.

With the support of the Department of Radiation Medicine at MUSC and Hollings, Warren has worked with cancer centers across the U.S. and Canada to set up smoking cessation programs. Through the Canadian Partnership Against Cancer, for example, he helped to increase smoking cessation programs in Canada from 26% of cancer centers in 2015 to 95% of cancer centers by 2023.

He also worked with the American College of Surgeons Commission on Cancer on the Just ASK and Beyond ASK Smoking Cessation initiatives, which addressed smoking across over 700 cancer centers in the United States.

But there is more work to be done, and smoking cessation may be one of the most effective methods of improving survival in the U.S. and internationally. He expects that this study will provide indisputable evidence as to the importance of smoking cessation programs at cancer centers.

"We now have a good estimate of how smoking cessation improves survival across cancer," Warren said. "This really shows us that if we provide an intervention, we improve survival."