1. ACC Cancer Plan Lung Cancer

2. Best for last ? First for last !

5. Education Prevention Access ACC Lung Cancer

6. Education Prevention Access ACC Lung Cancer

7. Tobacco and Disease: The 5 th Annual Lung Cancer Symposium November, 2014

10. http://www.cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo

11. Tobacco Umbrella CancersOther Lung Oropharynx Larynx Stomach Pancreas… Stroke Heart attack Bronchitis Emphysema PVD…

12. US Deaths Next Hour:

14. Prevention Adopt tax and price measures to reduce tobacco consumption Ban tobacco advertising, promotion and sponsorship Create smoke-free work and public spaces Put prominent health warnings on tobacco packages Combat illicit trade in tobacco products

15. Prevention “It is about an industry, and in particular these defendants, that survives, and profits from selling a highly addictive product which causes diseases that lead to a staggering number of deaths per year, an immeasurable amount of human suffering and economic loss, and a profound burden on our national health-care system. Defendants have known many of these facts for at least 50 years or more.” Judge Gladys Kessler, Final Order convicting the tobacco industry of racketeering and fraud in U.S. v Phillip Morris

21. Screening Everybody’s recommending it!

22. Lung Cancer Screening: Who is doing it? over 100 screening programs including: NCI Approved cancer centers across the US Academic centers Private non-academic hospital programs for-profit institutions

23. Lung Screening benefits and risks Potential Benefits Has the potential to detect cancer earlier and save lives find more cancers fewer cancer deaths (20% decrease) fewer deaths overall (6.7%) Potential harms invasive procedures in some participants false positives can create worry

24. Other screening modalities Not helpful: Chest Xray Sputum cytology bronchoscopy Potentially helpful Markers in urine Volatile organic compounds in breath protein markers in blood genes which demonstrate risk.

25. Lung cancer screening vs prevention Lung cancer is difficult to treat once it occurs. “an ounce of prevention is worth a pound of cure” B. Franklin

26. Screening is looking for: the needle in the haystack Number needed to treat 320 to save one life

27. Screening is not a test but a program Screening program tobacco cessation CT Scans outcomes research collect demographic data collect saliva

28. 443 356 87 Screening 26,722 screened $8,016,600

29. What’s wrong with screening Very inaccurate – 96% “positive” CTs were not lung cancer Very expensive

30. What’s wrong with screening Very inaccurate – 96% “positive” CTs were not lung cancer Very expensive Not clear it applies to AR Cannot be done the way it was in study There are better alternatives

31. Rules of Game NLST 55-74 yo with ≥ 30 pack-years Screen every year for 3 years 4mm or greater POSITIVE  No change for 2y → NEG NEJM 2011

32. California saved $86 billion in health care costs by spending $1.8 billion on tobacco control, a 50:1 return on investment over its first 15 years of funding its tobacco control program. http://www.cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo

33. Actionable Screening prospective approach to include  Enrollment screened patients into a database for future analysis as to efficacy  smoking cessation  pre-determined categories of suspicion for cancer  a treatment algorithm that included a group forum for discussion of difficult cases.

34. Actionable Screening A study of the biological characteristics of lung cancer that would have implications for screening.

35. Treatment Tobacco cessation Quality of care (access) Palliative care Elimination of disparities (access)

36. Give me your tired, your poor, Your huddled masses, yearning to breath free, The wretched refuse of your teeming shore, Send these, the homeless, tempest tost to me, I lift my lamp beside the golden door.

38. Statue of Addiction

39. Inalienable Rights The right to bear arms The right to smoke

40. Update released May 2008 Sponsored by the U.S. Department of Health and Human Services, Public Heath Service with: Agency for Healthcare Research and Quality National Heart, Lung, & Blood Institute National Institute on Drug Abuse Centers for Disease Control and Prevention National Cancer Institute www.surgeongeneral.gov/tobacco/ CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE HANDOUT

41. Tobacco users expect to be encouraged to quit by health professionals. Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001). Barzilai et al. (2001). Prev Med 33:595–599. Failure to address tobacco use tacitly implies that quitting is not important. WHY SHOULD CLINICIANS ADDRESS TOBACCO?

42. The 5 A’s: REVIEW ASK about tobacco USE ADVISE tobacco users to QUIT ASSESS READINESS to make a quit attempt ASSIST with the QUIT ATTEMPT ARRANGE FOLLOW-UP care

43. Faced with change, most people are not ready to act. Change is a process, not a single step. Typically, it takes multiple attempts. HOW CAN I LIVE WITHOUT TOBACCO? The (DIFFICULT) DECISION to QUIT

44. HELPING PATIENTS QUIT IS a CLINICIAN’S RESPONSIBILITY THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT. TOBACCO USERS DON’T PLAN TO FAIL. MOST FAIL TO PLAN. Clinicians have a professional obligation to address tobacco use and can have an important role in helping patients plan for their quit attempts.

45. Maintenance Contemplation Action Preparation Pre- contemplation Relapse * Not ready to quit Assess readiness to quit (or to stay quit) at each patient contact. For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time. ASSESSING READINESS to QUIT (cont’d)

46. Reasons/motivation to quit (or avoid relapse) Confidence in ability to quit (or avoid relapse) Triggers for tobacco use What situations lead to temptations to use tobacco? What led to relapse in the past? Routines/situations associated with tobacco use STAGE 3: PREPARATION Discuss Key Issues When drinking coffee While driving in the car When bored or stressed While watching television While at a bar with friends After meals During breaks at work While on the telephone While with specific friends or family members who use tobacco

47. “Smoking gets rid of all my stress.” “I can’t relax without a cigarette.” There will always be stress in one’s life. There are many ways to relax without a cigarette. THE MYTHS STRESS MANAGEMENT SUGGESTIONS: Deep breathing, shifting focus, taking a break. Smokers confuse the relief of withdrawal with the feeling of relaxation. STAGE 3: PREPARATION Discuss Key Issues (cont’d) THE FACTS Stress-Related Tobacco Use

48. Routinely identify tobacco users (ASK) Strongly ADVISE patients to quit ASSESS readiness to quit at each contact Tailor intervention messages (ASSIST) Be a good listener Minimal intervention in absence of time for more intensive intervention ARRANGE follow-up Use the referral process, if needed COMPREHENSIVE COUNSELING: SUMMARY

49. ASK about tobacco USE ADVISE tobacco users to QUIT REFER to other resources ASSIST ARRANGE BRIEF COUNSELING: ASK, ADVISE, REFER Patient receives assistance, with follow-up counseling arranged, from other resources such as the tobacco quitline

50. Brief interventions have been shown to be effective In the absence of time or expertise: Ask, advise, and refer to other resources, such as local group programs or the toll-free quitline 1-800-QUIT-NOW BRIEF COUNSELING: ASK, ADVISE, REFER (cont’d) This brief intervention can be achieved in less than 1 minute.

51. Address tobacco use with all patients. At a minimum, make a commitment to incorporate brief tobacco interventions as part of routine patient care. Ask, Advise, and Refer. MAKE a COMMITMENT…

52. METHODS for QUITTING Nonpharmacologic Pharmacologic Combination therapy is preferred.

53. NONPHARMACOLOGIC METHODS Cold turkey: Just do it! Unassisted tapering (fading) Reduced frequency of use Lower nicotine cigarettes Special filters or holders Assisted tapering QuitKey

54. PHARMACOLOGIC METHODS: FIRST-LINE THERAPIES Three general classes of FDA-approved drugs for smoking cessation:  Nicotine replacement therapy  Nicotine gum, patch, lozenge, nasal spray, inhaler  Psychotropics  Sustained-release bupropion  Partial nicotinic receptor agonist  Varenicline The e-cigarette is not an evidence-based cessation therapy

55. Survivorship Establishment of an ongoing care plan at end of therapy as part of routine management of every patient with cancer. Education of healthcare professionals. Establish for each patient a primary health care professional point of contact for the survivor’s care. Incorporation of survivor input into survivor care plans Open channels of communication. Health care professional to health care professional, health care professional to survivor, and survivor to survivor.

56. Education Prevention Access ACC Lung Cancer