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 rachel.roberts3@wales.nhs.uk 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 Rachel.Roberts3@wales.nhs.uk Tel: 01554 779309