As the New Year begins, so do the vows to turn over a new leaf and make
healthier choices: to spend more time at the gym, to eat fewer
cheeseburgers, to stop smoking. There is no better time for oncologists
to talk with their patients about lifestyle interventions and cancer
prevention. ASCO offers tools and resources to help start the
conversation.
Coordinating the Society’s efforts in the areas of risk and
prevention is the Cancer Prevention Committee, led by 2012-2013 Chair
Eva M. Szabo, MD, of the National Cancer Institute (NCI).
“Physicians are eager for information and more research on
cancer prevention,
| *Energy balance refers to the relationship between energy intake (nutrition) and energy expenditure (metabolic processes and physical activity). |
including tobacco cessation and energy balance.*
They know they ought to be talking with their patients about lifestyle
interventions, which are extremely difficult to put into practice, but
they typically don’t have the training or the tools for these
conversations, which are outside many people’s comfort
zone,” she said. “The Cancer Prevention Committee
looks for the best ways to help educate practicing clinicians in an
area that is often not taught thoroughly during our training. It also
seeks to provide information on cancer screening and cancer genetics,
which are rapidly evolving areas with clear significance for
prevention.”
Tobacco
cessation
Tobacco use is strongly correlated with cancer incidence, poorer
treatment outcomes (including slower recovery, higher risk of
infection, and higher toxicity from chemotherapy and radiation), and an
increased risk of cancer recurrence or development of a second primary
malignancy. At the same time, data from ASCO’s
Quality Oncology Practice Initiative (QOPI
®) indicates that tobacco
cessation counseling is not fully incorporated in many oncology
practices. ASCO launched a major tobacco cessation initiative in 2012,
with new resources available to aid physicians and patients with
discussions about tobacco use and quitting strategies, including
booklets for physicians and patients and an online toolkit. This initiative was led by the
Tobacco Cessation Subcommittee of the Cancer Prevention Committee.
“It’s important for oncologists to be on the front
lines of tobacco education and intervention for their patients because
patients are interested in this information: 70% of smokers
don’t want to be smokers, and half of smokers make a serious
attempt to quit every year,” said Nasser H. Hanna, MD, of
Indiana University Simon Cancer Center and a member of the Tobacco
Cessation Subcommittee. “Addiction to nicotine is exactly
like addiction to any other drug—multiple efforts to quit are
required for prolonged success. For physicians who have not had
resources or training for tobacco cessation counseling at their
disposal, ASCO has created a powerful set of tools.”
The physician guide includes comprehensive information and strategies
that can be used in daily practice:
Communicating with patients about their tobacco use and supporting
efforts to quit. Because it can be challenging, even awkward, to bring
up tobacco cessation with patients, the guide includes conversation
starters about a patient’s current tobacco use, attitudes
about quitting, and cessation strategies. Sample assessment tools for
patient tobacco use are provided. A particular emphasis is placed on
open-ended questions about the patient’s decisions and
feelings about tobacco use and cessation to avoid a situation of
blaming the patient for his or her choices. It also outlines the health
benefits of tobacco cessation, specifically as they relate to cancer
treatment outcomes and reducing the incidence of secondary cancers.
Treating nicotine dependence in patients with cancer. The guide
outlines evidence-based treatments for nicotine dependence, including
drugs approved by the FDA for this purpose. It provides sample
treatment plans based on the patient’s motivation to quit and
level of nicotine dependence, with a focus on whole-patient care and
incorporating behavioral counseling and pharmacologic interventions.
Reimbursement for tobacco cessation counseling and prescribed
medications. The guide notes that systematic barriers related to
tobacco cessation counseling exist for physicians, including confusion
about reimbursement. An overview of tobacco cessation coverage by
insurance type and coding specifics are provided. To help physicians
understand this information, suggested free online tobacco cessation
resources for patients and physicians are summarized in a table.The
scripts, assessments, and informational tables can be downloaded and
printed separately for use during individual patient visits.
The companion patient guide, “Stopping Tobacco Use after a
Cancer Diagnosis,” can be used in concert with in-person
discussions about tobacco cessation. The guide emphasizes that it is
never too late to benefit from tobacco cessation, even after a
diagnosis of cancer; debunks myths about quitting; explains information
about the patient’s tobacco use history that should be shared
with a physician; and outlines cessation strategies and resources. The
patient can fill out a personal “plan to quit tobacco
use” to assist with motivation and break down next steps for
tobacco cessation.
Patients can find this guide and other information about
cancer riskand prevention on Cancer.Net.
ASCO’s
physician and patient tobacco cessation guides are
available online at no cost as printable PDFs; a bundle of
professionally printed copies (10 provider booklets plus 115 patient
booklets) can be purchased for a nominal fee.
“The guides are excellent and very thorough. As a lung cancer
specialist, I think it’s very helpful to have these documents
to use in my daily practice,” Dr. Szabo said.
Energy
balance and weight loss
Two major focuses of the Cancer Prevention Committee in the coming year
are energy balance and the imperfectly understood correlation between
obesity and cancer (the subject of
one of NCI’s Provocative Questions in 2012). As more
research on these relationships emerges, the committee plans
to work jointly with ASCO’s Cancer
Survivorship Committee to develop guidance and recommendations
on weight and physical activity
in the areas of cancer risk, treatment outcomes, and risk of cancer
recurrence. The increasing awareness of
this issue in the oncology community
coincides with public health concerns in the United States, such as the
*Food and fitness deserts are areas, typically in urban settings, in which residents do not have convenient access to A) grocery
stores with fresh, affordable foods needed for a healthy diet or B) facilities, classes, or opportunities for physical activity.
|
long-term health complications stemming from childhood obesity,
questions of access related to food and fitness
“deserts,”* and improving understanding of
socioeconomic factors that
contribute to obesity.
“Obesity and diabetes have become major public issues, and
they are intimately linked with preventable causes of cancer.
We’re moving aggressively in this area to educate and provide
information and recommendations for practicing oncologists and
patients,” Dr. Szabo said.
Committee member Jennifer A. Ligibel, MD, of Dana-Farber Cancer
Institute, believes that oncologists have a crucial role to play in
encouraging patients to make healthy choices about energy balance, but
notes that more research and improved patient access to information and
resources are also paramount. “The Livestrong Foundation
partnered with the YMCA to create one of the first national programs
for increased activity for patients with cancer. We need similar
programs in weight loss and dietary counseling. We need real research
to determine what human behaviors make a difference after a cancer
diagnosis and what changes are most effective,” she said.
The current lack of clear, direct guidance on energy balance and cancer
prevention can lead some patients to eschew the pathway of increased
physical activity and a healthy diet for unproven—and
potentially dangerous—supplements.
“There is so much misinformation
out there,” Dr. Ligibel said. “Eating a diet with
lots of fruits and vegetables
is not as exciting as the promise of
fixing everything with a pill. We need
to provide guidance to oncologists about some of these supplements so
they can counsel their patients: what’s safe,
what’s not, and what the side effects are.”
Cancer
screening, risk assessment, and
management
The Cancer Prevention Committee is actively working to provide guidance
and information in the areas of cancer
screening and overall cancer risk assessment and management,
particularly as it relates to hereditary cancer risk.
The Cancer Prevention Committee has supported the Clinical Practice
Guidelines Committee in creating recommendations related to screening
for specific cancers, a crucial aspect of a cancer prevention program.
In 2012, ASCO published two new screening guidelines and related
clinical tools:
A guideline has also been published on chemoprevention for breast
cancer (
Use of Pharmacologic Interventions Including Tamoxifen, Raloxifene, and Aromatase Inhibition for Breast Cancer Risk Reduction).
In the area of familial cancer risk, the Cancer Prevention Committee
has played a leadership role in educating the oncology community for
more than a decade. In 2012, a conference on family history was
organized, with the purpose of defining the minimum family history that
oncologists should assess. This stemmed from data collected from QOPI
on genetic counseling practices, which demonstrated that while
oncologists often document a patient’s first-degree family
history of cancer, many practices do not routinely assess the history
of second-degree relatives or the age at which family members were
diagnosed with cancer.
This in-depth family history “is necessary to determine the
patient’s risk of developing a second cancer,” said
Marie Wood, MD, of the University of Vermont and a member of the Cancer
Prevention Committee. “Right now there are no standards for
collecting this information.” The committee plans to define
the minimum standards based on expert consensus to assist oncologists
in providing better counseling on individual cancer risk and prevention
strategies.
In May, a 1.5-day seminar on “
Genetics and Genomics for the Practicing Clinician” will be offered as one of
ASCO’s Pre-Annual Meeting Seminars. The course will cover
tumor and germ-line topics, discuss the variety of tests available to
the clinician, and share best practices for administering genetic
testing.
The challenges of cancer prevention are real, and additional research
is required in many areas. But the benefits of investing time and
resources in prevention are significant. “When one combines
lifestyle interventions, judicious screening, and possibly
pharmacologic interventions, the potential to make a difference in the
cancer burden is huge,” Dr. Szabo said. “The field
of prevention offers enormous opportunity to change cancer care in a
positive way.”
By Virginia Anderson, Senior
Writer/Editor
Practicing What You Preach
Physicians empathize with patients about the challenges of a healthy lifestyle
By Faith Hayden, ePublishing Specialist
Oncologists,
like their patients, don’t take perfect care of
their own health and struggle to make healthy choices when stresses
from work, family, and other commitments pile up. It can feel
hypocritical to encourage a patient to make a significant lifestyle
change when the physician knows that he or she isn’t the
model of healthy behavior.
ASCO Connection spoke with two oncologists
on ASCO’s Cancer Prevention Committee who stress positive
lifestyle choices to their patients and use their own challenges and
experiences as a starting point for the conversation.
Cancer Prevention Committee Chair
Eva M. Szabo, MD, resolved to improve her health several years ago when
she first began an exercise regimen, but it was not until her children
went off to college in September 2012 that she could devote sufficient
energy to exercise and diet to meet her goals for weight loss.
“I aim for four to five workouts per week, and although I
don’t manage that every week, I’ve achieved this
goal most of the time,” she said. “I’ve
gone on a diet and have lost some weight. I’m making an
effort to live what I’m preaching to others, and the area
where I’m making the biggest change is in my energy balance,
for several reasons—cardiovascular as well as cancer
prevention.”
Dr. Szabo admits that prior to embarking on a new, healthier lifestyle,
she didn’t exercise much for most of her adult life and
thought a “runner’s high was a myth.” Now
she says that personal experience has taught her that “once
you get into an exercise program, you really do feel better.”
Though Cancer Prevention Committee member Jennifer Ligibel, MD,
describes herself as a “life-long exerciser,” she
admits that a workout and managing a healthy diet are harder to squeeze
in to her schedule than they used to be.
“I have young children, a full-time job, and
there’s a lot of juggling that goes on,” Dr.
Ligibel said. “I do exercise regularly, but it’s
three days a week instead of the six it used to be. And there are days
when I have pizza for dinner because I’m too tired to make
something else, and that’s what the kids are
having.”
Dr. Ligibel doesn’t believe these personal challenges make it
difficult to talk to patients about their lifestyle choices; if
anything, it makes her more empathetic to their setbacks.
“I think my own need for a balance makes me better at
relating to some of the challenges my patients have,” she
said. “Before, when I was biking 70 miles a week, it was
sometimes hard for me to understand, ‘Well what do you mean
you can’t get in a half-hour walk at lunch
time?’”
Now, when Dr. Ligibel speaks to a patient about increasing activity or
weight loss, she is able to give practical tips. For example, if a
patient has small children, she might suggest buying a double jogging
stroller and going out for a run with the kids after work. If that
doesn’t work, she may recommend a commercial weight-loss
program.
“Give people very clear instructions.
Not—‘This is what you should do,’ but
‘This is how you do it,’” Dr. Ligibel
said. “There’s no blaming or implying that the
patient didn’t try hard enough. The focus is on what we can
do about it now.”
Share your healthy lifestyle
stories or challenges in the comments below.