Transcript The winning project LungCast co-ordinated by Dr Keir

LungCAST
Does smoking status after a diagnosis of lung
cancer affect outcomes?
Rachel Roberts, Robin Ghosal, Ian Campbell, Helen
Davies, Diane Parry, Gareth Collier, & Keir Lewis
This research has been funded by The Global Research Awards for Nicotine Dependence
Background
Why is this research important?
Aims of Study
What are we looking for?
Method
How do we collect and record data?
Study Outcomes
What do the results show?
Future Plans
Where next?
Smoking Causes Lung Cancer

Smoking causes over 85% of lung cancer
(Peto et al, 2000)
Background
• 47% of patients with Lung Cancer were smoking
at the time of diagnosis
• Retrospective and self-reported studies suggest
that continued smoking after a diagnosis of
Lung Cancer (LC) independently worsens
quality of life, and shortens life expectancy.
• Studies suggest that stopping smoking can
potential increase life expectancy by around 3-6
months, at least in early stage cancer.
Effect on Treatment
Smoking can alter rate of metabolism for several drugs inc.
those used in chemotherapy
Smoking related to more chemo-resistant tumors (Volm et
al, 1999)
Smoking can decrease effectiveness of RT (Grau et al,
1994) & increase complications (Nieder & Bremnes, 2008)
Effects recovery from surgery and complications post-op
Problems with studies
– No prospective studies
– Smoking status only self reported
– Smoking reported only at baseline not
account for quitters or relapsers
– No controls i.e. could stopping smoking
merely be a marker for other healthy
behaviours?
– Mechanisms of how therapy is affected
by smoking?
Longitudinal Observational
Study
See if smoking status, after clinical diagnosis
of LC independently influences survival
Compare
survival rates
Compare
by smoking
treatment
status for early
complications
Vs advanced
NSCLC
Compare
quality of life
and
performance
status
Method
Participants
• 2400 patients
• Newly diagnosed with Lung Cancer regardless of smoking
• Recruiting in 23 hospital across Wales and England
Recruitment
•Consented prior to starting treatment
•Within 1 month of diagnosis
Baseline
Data
Follow up
Data
• Patient demographics (age, gender), Clinical Variables, Medical history,
Cyto/histological diagnosis, Staging (TNM), Health related quality of life
(measured by EQ5D), assessment of smoking status (Validated by eCO)
•1, 3, 6, 12 and 24 months as per current lung cancer clinical protocols.
• Exhaled CO & EQ5D at each visit.
Results
Variable
Smokers
(n=172)
Non-smokers
(n=231)
P-Value
Mean Age
65.26 (9.87)
69.61 (9.57)
0.000
Mean Weight
(Kg)
71.06 (16.96)
75.66 (15.19)
0.007
Mean T Stage
2.88 (1.19)
2.43 (1.13)
0.012
Mean N
Stage
1.67 (1.09)
1.62 (1.17)
0.765
Mean M
Stage
0.38 (0.49)
0.43 (0.55)
0.514
PS
1.20 (0.89)
1.00 (0.84)
0.260
Current or ex smokers are younger (F (2, 108) =
3.988, p = .021) and have higher T staging (F (2,
79) = 4.617, p = .013) at the time of lung cancer
diagnosis than never smokers.
Smoking affects tumor size, supporting
previous research.
LungCAST
Effect of smoking following a diagnosis of lung cancer
Keir Lewis(1,2) & Rachel Roberts (1,2)
1. Hywel Dda Health Board, Wales, UK. 2. College of Medicine, Swansea University, Wales, UK.
Introduction
Tobacco smoking causes over 80% of lung
cancer but the importance of smoking after a
diagnosis of lung cancer has only been reported
retrospectively and not
biologically validated.
Retrospective and self-reported studies suggest
that continued smoking is associated with worse
outcomes in Lung Cancer (LC) patients.
LungCAST (REC 09/WMW01/28, UKCRN 9851)
is a longitudinal study examining the influence of
smoking status at the time of lung cancer
diagnosis and effect of cessation on outcomes.
Aims
Methods
Following ethical approval, data was collected
from all consecutive attendees to Rapid Access
Lung Clinics and any inpatients suspected or
recently diagnosed with lung cancer.
403 newly diagnosed LC patients were followed
up over 6 months and data was collected with
regards to smoking status, performance status
(PS), mortality and treatment complications. Selfreported smoking status was verified by exhaled
carbon monoxide (eCO) levels at each visit.
Anyone who admitted to smoking or had an
eCO>10 parts per million were deemed smokers.
Pack years were calculated based on duration
and amount smoked.
Results
The table illustrates smokers and non smokers at
the time of diagnosis.
Aims
Variable
Smokers
(n=172)
Non-smokers
(n=231)
P-Value
Mean Age
65.26 (9.87)
69.61 (9.57)
0.000
Mean Weight
(Kg)
71.06 (16.96)
75.66 (15.19)
0.007
Mean T Stage
2.88 (1.19
2.43 (1.13)
0.012
Mean N
Stage
1.67 (1.09)
1.62 (1.17)
0.765
Mean M
Stage
0.38 (0.49)
0.43 (0.55)
0.514
PS
1.20 (0.89)
1.00 (0.84)
0.260
6 month survival was slightly improved in nonsmokers (69.1%) compared to smokers (67.6%)
however this was not significantly significant
(p=0.492).
The table illustrates smokers and non smokers six
months following diagnosis.
Variable
Smokers
(n=110)
Non-smokers
(n=136)
P-Value
Mean PS
1.32 (0.83)
0.98 (0.62)
0.047
Complications
(%)
37.3%
31.6%
0.022
Smokers had a significantly poorer performance
status 6 months after diagnosis compared to nonsmokers (t(69) = -2.02, p = 0.047). There was no
significant difference in those who quit smoking
after diagnosis.
Conclusion
Smoking at time of lung cancer diagnosis
increases occurrence of complications and
decreases performance status six months after a
diagnosis of LC after accounting for known
confounders. Quitting smoking following a
diagnosis was associated with a decrease in the
rate of complications but there was no statistically
significant effect on mortality, this could be due to
the size of this cohort.
These findings indicate that quitting smoking will
improve outcomes in LC patients, suggesting that
smoking cessation should be provided more often
and more intensely at the time of diagnosis.
Further data collection regarding histology,
treatments and clinical outcomes is ongoing in
order to determine the effects of quitting smoking
on prognosis and outcomes.
Smokers had increased number of complications
at 6 months (X2 (5) = 13.126, p =0.022). Those
who quit smoking after a diagnosis of LC
experienced less complications within the 6
months following diagnosis than patients who
continued to smoke (X2 (1, N = 79) = 8.050, p
=0.005)
Continued to smoke
Quit smoking
As part of this larger UK multicentre study (14
sites) we wish to asses the extent to which
smoking status affects outcomes six months
after a diagnosis.
Contact
0
10
20
30
40
50
60
% of patients who experienced complications
Funded by a grant from The Global Research Awards for Nicotine Dependence (Pfizer
Inc)
Figure 2: % of complications in patients who quit
smoking after a diagnosis of LC compared to those
who continued to smoke.
Rachel Roberts
[email protected]
Tel: +44 1554 779309
Survival
6 month survival was slightly improved in nonsmokers (69.1%) compared to smokers
(67.6%) however this was not significantly
significant (p=0.492).
6 month survival
69.50%
69.00%
68.50%
68.00%
67.50%
67.00%
66.50%
Non-smokers
Current Smokers
Performance status
• Smokers had a significantly poorer
performance status at 6 months after diagnosis
compared to non-smokers (t(69) = -2.02, p =
0.047)
Performance status
1.4
1.2
1
0.8
0.6
0.4
0.2
0
(n=110)
(n=136)
Smokers
Non-smokers
• There was no significant difference on QoL
Treatment Complications
Smokers had increased number of complications at
6 months (X2 (5) = 13.126, p =0.022)
Those who quit smoking after a diagnosis of LC
experienced less complications within the 6 months
following diagnosis than patients who continued to
smoke (X2 (1, N = 79) = 8.050, p =0.005)
Implications
These findings indicate that quitting smoking is
associated with less treatment complications in
LC patients
The influence on survival is still being measured
but we need larger numbers
Quitting Smoking impacts outcomes in patients with
Lung Cancer
NICE Guidelines
1.4 Treatment
Smoking cessation
1.4.1 Inform patients that smoking increases the risk of pulmonary complications after lung cancer surgery. [new 2011]
1.4.2 Advise patients to stop smoking as soon as the diagnosis of lung cancer is suspected and tell them why this is
important. [new 2011]
1.4.3 Offer nicotine replacement therapy and other therapies to help patients to stop smoking in line with Smoking
cessation services (NICE public health guidance 10) [new 2011]
Nice Guidelines: CG121 - Lung cancer: The diagnosis and treatment of lung cancer
Where next?
• Further data collection regarding influence of
smoking on histology, staging, change in QoL,
complications for specific treatments and
clinical outcomes is ongoing
• Closure of RCT
• Future studies:
– Evaluation of Smoking Cessation Strategies in
Lung Cancer Patients: Developing a Tailored and
Specialist Service
41% of smokers enrolled in LungCAST wanted to
quit smoking
Less than a third had successfully quit within 6
months of diagnosis.
Evaluation of those who did not want quit cited a
number of reasons:
•
•
•
•
•
•
•
Have enough going on in their lives (23%)
Feel too anxious to quit (20%)
Don’t think there is any point in quitting (17%)
Enjoy smoking (14%)
Would eventually like to quit but are not ready at this time (12%)
Think they will fail (9%)
Feel that they are too old (5%)
Proposed qualitative study
• Investigate barriers to smokers with a
diagnosis of LC in attending a HSCS
(patient and health care workers)
• By identifying barriers we can generate a
more appropriate cessation service
• Regulatory approvals in Nov 2013
Background
Quitting smoking improves prognosis
Aims of Study
Determine benefits of quitting
Method
Study Outcomes
Smoking effects QoL and outcomes
Future Plans
Follow-up data and qualitative study
Contact information
Rachel Roberts
Portfolio Research Coordinator
Clinical Research Centre
Prince Phillip Hospital
Llanelli
SA14 8QF
[email protected]
Tel: 01554 779309