Committee Connection

Improving Outcomes: Discussing Healthy Lifestyle Choices with Your Patients

19 Dec 2012 9:22 PM

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.”

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