美国癌症研究协会设法限制癌症患者吸烟

华盛顿——4月9日美国癌症研究协会(AACR)年会的新闻发布会上公布了一则新政策声明，旨在帮助癌症患者戒烟，鼓励更多的医生将使用烟草作为临床试验的一项指标和一项关键的生命体征。发言人兼撰写者Roy S. Herbst医生是AACR烟草与癌症附属委员会成员，同时也是美国耶鲁大学癌症研究中心和Smilow癌症医院肿瘤内科主任。

Roy S. Herbst医生

专家们在这则声明中呼吁肿瘤界评估并记录所有癌症患者烟草的使用情况，并为这些患者提供戒烟支持。报告中的两条主要建议为：

· 给予癌症患者、癌症试验受试者以及正在接受癌症筛查并且吸烟的或最近刚戒烟的患者以循证的戒烟支持，最好在肿瘤医疗实践中实施。

· 对所有的癌症患者均应全面反复地记录烟草使用，无论在实践中还是试验中，以便判断吸烟对治疗、病情进展、并发症及生存的影响。

由于所有癌症相关死亡中多达1/3、肺癌死亡中有87%归因于烟草的使用，因此设法解决吸烟问题迫在眉睫。在18种不同类型的癌症发生原因中均有吸烟的因素。预防是目标，但督促癌症患者或癌症生存者戒烟也很重要，因为吸烟会使患者的结局更差，并增加治疗难度。根据这则政策声明，吸烟可降低化疗的有效性，干扰药物代谢。数据还表明，吸烟可减少肺部、头颈部、乳腺、前列腺、结肠、食管、宫颈、膀胱及卵巢等部位癌症以及白血病患者的生存时间。

美国公共卫生服务部设计的循证戒烟模型得到了AACR、美国临床肿瘤学会及其他学会的认可，但很少有临床医生提供戒烟服务。AACR委员会也报告称，仅38%的国立癌症研究所指定的癌症中心将吸烟记录为一项生命体征，不足半数设有专门的戒烟人员。而且，在一项由国际肺癌研究学会进行的调查中，仅有40%的肺癌专家称其探讨过戒烟药物或为患者提供过戒烟支持。对癌症患者做的烟草评估可能低于预期水平，这在一定程度上是由于医生和患者感觉太晚戒烟没有意义。

相关费用也是个问题。尽管Medicare每年报销8次咨询就诊费用，但戒烟的费用在过去一般不报销。《可负担医疗法案》要求所有的保险公司从2014年开始报销戒烟费用。耶鲁大学Smilow癌症医院精神病专家、戒烟服务项目主任Benjamin A. Toll医生指出，过去的报销情况确实差强人意，报销额度也不太高，但会越来越好。

临床医生和研究者们在评估临床试验中的烟草使用方面并未下足功夫。对155项NCI联合组试验进行的一项调查表明，仅29%的试验在募集受试者时评估了吸烟情况；在试验过程中记录吸烟状况的更是少之又少。不足5%在试验过程中及之后追踪了吸烟状况。没有一项研究评估尼古丁依赖性或患者的戒烟意愿。

《评估癌症患者烟草使用及辅助戒烟》是AACR发出的关于烟草使用的第三则声明，在线发表于《临床癌症研究》上(2013;19:1-8)。

这则新政策声明由Herbst医生报告，他本人收到了由Biothera、Diatech及Quintiles公司提供的咨询费。Toll先生报告称获得了辉瑞公司提供的药物支持。

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By: ALICIA AULT, Internal Medicine News Digital Network

WASHINGTON – A new policy statement aims to help cancer patients to quit using tobacco and encourage more physicians to consider tobacco use as a measure in trials and as a key vital sign.

"Today, we call on the oncology community in this statement to assess and document tobacco use by, and to provide cessation support to all cancer patients," Dr. Roy S. Herbst said at a press briefing April 9 at the annual meeting of the American Association for Cancer Research.
 
Dr. Herbst is a member of the AACR Tobacco and Cancer Subcommittee that wrote the statement, and chief of medical oncology at Yale Cancer Center and Smilow Cancer Hospital at Yale-New Haven in Conn.

The report’s two main recommendations:

· Patients with cancer, participants in cancer trials, and patients being screened for cancer and who use tobacco or who have recently quit, should be given evidence-based tobacco-cessation assistance, ideally within an oncology practice.

· Tobacco use should be comprehensively and repeatedly documented in all cancer patients – both in practices and in trials – so as to gauge the effect of tobacco on treatment, disease progression, comorbidities, and survival.

Addressing tobacco use is urgent because up to a third of all cancer-related deaths and 87% of lung cancer deaths are because of tobacco use, Dr. Herbst said. Tobacco use plays a role in 18 different cancers. Prevention is the goal, but it’s also important to urge people who have cancer – or who have survived it – to stop using tobacco, he said.

Patients who use tobacco have worse outcomes and more difficult treatment. According to the policy statement, tobacco use decreases the effectiveness of chemotherapies and interferes with drug metabolism. The data also shows that it decreases survival in cancer of the lung, head and neck, breast, prostate, colon, esophagus, cervix, bladder, and ovaries and in leukemia.

Evidence-based tobacco cessation models developed by the U.S. Public Health Service are endorsed by the AACR, the American Society of Clinical Oncology, and others, and yet few clinicians offer cessation services.

The AACR committee also reported that only 38% of National Cancer Institute–designated Cancer Centers record smoking as a vital sign and less than half have dedicated tobacco cessation personnel. And, in a survey by the International Association for the Study of Lung Cancer, only about 40% of lung cancer specialists said they discussed medication or offered cessation support to patients.

Tobacco assessment in cancer patients may be underperformed in part because of physician and patient perceptions that it’s too late to have an impact, Dr. Herbst said. "There is the feeling that someone’s smoking, they already have cancer, why worry about it."

There is also the issue of payment.

Smoking cessation generally has been not covered in the past, although Medicare covers up to eight visits a year for counseling. The Affordable Care Act requires coverage of tobacco cessation by all insurers starting in 2014.

"It’s true that reimbursement in the past was very poor," said Benjamin A. Toll, Ph.D., a psychiatrist and program director of the smoking cessation service at Smilow Cancer Hospital at Yale-New Haven. "It’s still not particularly high, but it’s getting better," he said, at the briefing.

Clinicians and researchers also have not been diligent about assessing tobacco use in trials. A survey of 155 NCI Cooperative Group Trials showed that only 29% of trials assessed tobacco use at enrollment; far fewer recorded smoking status during the trial. Less than 5% followed up subsequently on tobacco use status during or after the trial.

None of the studies evaluated nicotine dependence or the patient’s interest in quitting.

"It really is incredible that so many of these NCI trials are done and these data are not recorded," said Dr. Herbst.

"Assessing Tobacco Use in Cancer Patients and Facilitating Cessation" is the third statement on tobacco use by the AACR, published online in Clinical Cancer Research (2013;19:1-8).

The statement was Dr. Herbst reported that he received consulting fees from Biothera, Diatech, and Quintiles. Mr. Toll reported that he received support from Pfizer, for medicine only.