How can patients who are not referred for treatment receive the best treatment available?

Authors


As authors of the article entitled “Automated Tobacco Assessment and Cessation Support for Cancer Patients” that was recently published in Cancer,[1] we appreciate the editorial comments released simultaneously online by Rabius et al.[2] However, the editorial did not accurately reflect the main goal of our study. Rabius et al imply that that we were recommending minimal assistance for smoking cessation. Our purpose was not to recommend that patients receive minimal care, but rather to point out the feasibility of widening the reach of smoking cessation through an automated tobacco assessment and referral system.

Virtually no one would question the benefits of offering tobacco cessation support to patients with cancer. However, 2 recent surveys demonstrate that, whereas nearly all oncologists assess tobacco use and routinely advise patients to stop using tobacco, fewer than one-half report regularly providing tobacco cessation assistance.[3, 4] As a result, a substantial percentage of patients with cancer receive no cessation assistance at all, much less the type of services discussed by Rabius et al.[2] Rabius et al[2] confirm that the implementation of automatic referrals at their institution increased referrals by 250%. These statistics appear to validate our claim that the automatic referral of all smokers will greatly increase the reach of cessation assistance over that provided through voluntary referral initiated only by the oncologist.

The tobacco cessation service at The University of Texas MD Anderson Cancer Center (MDACC) is exceptional, with support coming from research resources and funds earmarked from the Tobacco Settlement Fund of the state of Texas.[5] As described online, the MDACC tobacco cessation services consists of “…approximately two hours in our clinic during the first visit. Follow-up visits are approximately 45 to 60 minutes. The program usually involves a total of six to eight visits.” This commendable effort comprises 6.5 to 8 hours of cessation intervention for each patient (ie, 2 hours for the first visit followed by 6-8 visits of 45 minutes per visit), which in many cases likely exceeds the amount of direct face-to-face physician support that patients get for other elements of their cancer care. Clearly, every cancer center should want dedicated, well-supported professional resources and infrastructure support for clinical services that should include tobacco cessation. However, the reality is that not many cancer centers have the resources to support the type of tobacco cessation services provided by MDACC, nor is there compelling evidence to suggest that all patients require such an intensive intervention. Even assuming that more intensive intervention would be more effective, the magnitude of the improvement is not yet known. Reliance on such an intense intervention in the face of limited and fixed staff resources could limit the number of patients that could be treated.

An important aspect of our report was the observation that the overwhelming majority of patients approached were receptive to telephone intervention.[1] This very significant observation contradicts physician views that poor patient interest is the primary barrier to providing cessation support.[3, 4] It is possible and probably likely that higher-intensity tobacco cessation support, with substantially increased resources, would be more effective than the service we implemented. However, Rabius et al[2] state that 65% of patients at MDACC are treated with telephone-based counseling and that “follow-up sessions may be done over the phone (15-20 minutes each) when traveling to MD Anderson is not feasible.”[5] This suggests that telephone-based support may be a viable option even within the context of a more intensive tobacco cessation service.

There is simply no question: patients who are not referred for treatment cannot possibly receive the best treatment available. Our study demonstrated that an automated tobacco assessment and referral to a cessation program using telephone-based cessation support is a feasible, clinically efficient way to reach and assist patients with cancer in tobacco cessation efforts. Perhaps this method of assessment and referral would facilitate access to more intensive support systems when available.

  • Graham W. Warren, MD, PhD

  • Department of Radiation Oncology

  • Medical University of South Carolina

  • Charleston, South Carolina

  • James R. Marshall, PhD

  • Division of Cancer Prevention and Population Science

  • Roswell Park Cancer Institute

  • Buffalo, New York

  • K. Michael Cummings, PhD

  • Department of Psychiatry and Behavioral Science

  • Medical University of South Carolina

  • Charleston, South Carolina

  • Anurag K. Singh, MD

  • Department of Radiation Medicine

  • Roswell Park Cancer Institute

  • Buffalo, New York

  • Mary E. Reid, PhD

  • Department of Medicine

  • Roswell Park Cancer Institute

  • Buffalo, New York

FUNDING SUPPORT

Supported in part by the Roswell Park Alliance Foundation and the American Cancer Society (MRSG-11-031-01-CCE to Dr. Warren).

CONFLICT OF INTEREST DISCLOSURES

Dr. Cummings serves as an expert witness for the plaintiffs in tobacco litigation cases.