Pearls of Wisdom: Smoking Cessation After Lung Cancer Diagnosis
Marge, a 62-year-old woman, 2 weeks ago received a diagnosis of non-small cell lung cancer. She has been a lifelong smoker (60 pack-year history), and you see a pack of cigarettes in her purse at today’s visit.
Her lung cancer had been diagnosed with low-dose computed tomography (CT). She is asymptomatic and has been told that her lesion is not amenable to resection, so radiation and chemotherapy will be her preferred treatment.
You have counseled Marge repeatedly over a long clinical relationship about the toxicities of smoking and the advantages of smoking cessation, but she has never been motivated to stop.
Assistive attempts (nicotine, varenicline, bupropion, hypnosis, etc) have been offered, but she has rejected these options.
She has been told that her prognosis is approximately 18 months.
At this point, what advice would be appropriate?
A. It’s never too late to quit: Smoking cessation will still reduce mortality.
B. At this point, smoking cessation will not reduce mortality, but it will improve overall quality of life.
C. At this point, she might as well continue to smoke if she enjoys it, since cessation will not meaningfully impact her outcome.
D. Continuing to smoke will worsen mortality.
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.
Answer: At this point, smoking cessation will not reduce mortality, but it will improve overall quality of life.
Amazingly enough, person-on-the-street polls over the past 2 decades have reported that almost half of smokers say that no health professional has ever told them that they need to stop smoking. In any case, our repeated messages to patients about the values of smoking cessation have been shown to ultimately improve quit rates, albeit modestly.
Smoking Cessation: Don't Give Up on Older Adults
Helping an Older Man Quit Smoking
But what about the person who already has lung cancer? The patient has perhaps already received multiple messages and opportunities to stop, but has not chosen to follow them up.
I have faced this situation many times with patients, and two too many times personally: My mother and brother were both long-term smokers, and both died of lung cancer. Would smoking cessation advice, even after the diagnosis of lung cancer, be of any benefit?
A 2006 study makes the answer to this question very clear: It is never too late to stop smoking.
The study included all non-small cell lung cancer cases seen at the University of Texas MD Anderson Cancer Center in Houston over an 11-month period. All study participants (N=93) were still smoking at the time of enrollment. The Eastern Cooperative Oncology Group (ECOG) scale was used to assess capacity for activities.
Study participants were followed for 12 months. Participants who quit smoking were compared with nonquitters.
ECOG Performance Status Scale Descriptors
In the first 6 months of follow-up, almost 3 times as many nonquitters experienced a worsening ECOG performance scale score as those who stopped smoking (57.6% vs 22.9%). Similarly, almost twice as many persons who quit smoking experienced an improvement in ECOG as nonquitters (77.2% vs. 42.4%). During the next 6-month period of the study, the differences between the groups disappeared. This is because so many of the participants had become ill by this time in the disease process that there was little demonstrable difference. There was no difference in overall mortality.
So what do we learn from this? In the short time of life lung cancer patients have remaining after their diagnosis, those who quit will have substantially better performance.
I couldn’t bring myself to go to my brother’s bedside and dispense what he would surely have viewed as "Sermon #10,000," since I had already tried all measures within reason (and some a margin beyond) to help him achieve nonsmoker status. I am confident he would have been just as resistant to a message about the benefits of smoking cessation even after a diagnosis of lung cancer as he had been before.
But this has not deterred me from informing patients in the same situation about the fact that it is never too late.
Smoking Cessation and Performance Status
What’s the “Take Home”?
Even after a diagnosis of lung cancer, smoking cessation can improve function over the limited lifespan left to the patient.
1. Baser S, Shannon VR, Eapen GA, et al. Smoking cessation after diagnosis of lung cancer is associated with a beneficial effect on performance status. Chest. 2006;130(6):1784-1790.