Improving Outcomes: Discussing Healthy Lifestyle Choices with Your Patients

Dec 19, 2012

As the New Year begins, so do the vows to turn over a new leaf and makehealthier choices: to spend more time at the gym, to eat fewercheeseburgers, to stop smoking. There is no better time for oncologiststo talk with their patients about lifestyle interventions and cancerprevention. ASCO offers tools and resources to help start theconversation.

Coordinating the Society’s efforts in the areas of risk andprevention is the Cancer Prevention Committee, led by 2012-2013 ChairEva M. Szabo, MD, of the National Cancer Institute (NCI).“Physicians are eager for information and more research oncancer prevention,

including tobacco cessation and energy balance.*They know they ought to be talking with their patients about lifestyleinterventions, which are extremely difficult to put into practice, butthey typically don’t have the training or the tools for theseconversations, which are outside many people’s comfortzone,” she said. “The Cancer Prevention Committeelooks for the best ways to help educate practicing clinicians in anarea that is often not taught thoroughly during our training. It alsoseeks to provide information on cancer screening and cancer genetics,which are rapidly evolving areas with clear significance forprevention.”

Tobacco cessation
Tobacco use is strongly correlated with cancer incidence, poorertreatment outcomes (including slower recovery, higher risk ofinfection, and higher toxicity from chemotherapy and radiation), and anincreased risk of cancer recurrence or development of a second primarymalignancy. At the same time, data from ASCO’s Quality Oncology Practice Initiative (QOPI®) indicates that tobaccocessation counseling is not fully incorporated in many oncologypractices. ASCO launched a major tobacco cessation initiative in 2012,with new resources available to aid physicians and patients withdiscussions about tobacco use and quitting strategies, includingbooklets for physicians and patients and an online toolkit. This initiative was led by theTobacco Cessation Subcommittee of the Cancer Prevention Committee.

“It’s important for oncologists to be on the frontlines of tobacco education and intervention for their patients becausepatients are interested in this information: 70% of smokersdon’t want to be smokers, and half of smokers make a seriousattempt to quit every year,” said Nasser H. Hanna, MD, ofIndiana University Simon Cancer Center and a member of the TobaccoCessation Subcommittee. “Addiction to nicotine is exactlylike addiction to any other drug—multiple efforts to quit arerequired for prolonged success. For physicians who have not hadresources or training for tobacco cessation counseling at theirdisposal, ASCO has created a powerful set of tools.”

The physician guide includes comprehensive information and strategiesthat can be used in daily practice:

Communicating with patients about their tobacco use and supportingefforts to quit. Because it can be challenging, even awkward, to bringup tobacco cessation with patients, the guide includes conversationstarters about a patient’s current tobacco use, attitudesabout quitting, and cessation strategies. Sample assessment tools forpatient tobacco use are provided. A particular emphasis is placed onopen-ended questions about the patient’s decisions andfeelings about tobacco use and cessation to avoid a situation ofblaming the patient for his or her choices. It also outlines the healthbenefits of tobacco cessation, specifically as they relate to cancertreatment outcomes and reducing the incidence of secondary cancers.

Treating nicotine dependence in patients with cancer. The guideoutlines evidence-based treatments for nicotine dependence, includingdrugs approved by the FDA for this purpose. It provides sampletreatment plans based on the patient’s motivation to quit andlevel of nicotine dependence, with a focus on whole-patient care andincorporating behavioral counseling and pharmacologic interventions.

Reimbursement for tobacco cessation counseling and prescribedmedications. The guide notes that systematic barriers related totobacco cessation counseling exist for physicians, including confusionabout reimbursement. An overview of tobacco cessation coverage byinsurance type and coding specifics are provided. To help physiciansunderstand this information, suggested free online tobacco cessationresources for patients and physicians are summarized in a table.Thescripts, assessments, and informational tables can be downloaded andprinted separately for use during individual patient visits.

The companion patient guide, “Stopping Tobacco Use after aCancer Diagnosis,” can be used in concert with in-persondiscussions about tobacco cessation. The guide emphasizes that it isnever too late to benefit from tobacco cessation, even after adiagnosis of cancer; debunks myths about quitting; explains informationabout the patient’s tobacco use history that should be sharedwith a physician; and outlines cessation strategies and resources. Thepatient can fill out a personal “plan to quit tobaccouse” to assist with motivation and break down next steps fortobacco cessation.

Patients can find this guide and other information about cancer riskand prevention on Cancer.Net.

ASCO’s physician and patient tobacco cessation guides areavailable online at no cost as printable PDFs; a bundle ofprofessionally printed copies (10 provider booklets plus 115 patientbooklets) can be purchased for a nominal fee.

“The guides are excellent and very thorough. As a lung cancerspecialist, I think it’s very helpful to have these documentsto use in my daily practice,” Dr. Szabo said.

Energybalance and weight loss
Two major focuses of the Cancer Prevention Committee in the coming yearare energy balance and the imperfectly understood correlation betweenobesity and cancer (the subject of one of NCI’s Provocative Questions in 2012). As moreresearch on these relationships emerges, the committee plansto work jointly with ASCO’s CancerSurvivorship Committee to develop guidance and recommendationson weight and physical activityin the areas of cancer risk, treatment outcomes, and risk of cancerrecurrence. The increasing awareness ofthis issue in the oncology communitycoincides with public health concerns in the United States, such as the

long-term health complications stemming from childhood obesity,questions of access related to food and fitness“deserts,”* and improving understanding ofsocioeconomic factors thatcontribute to obesity.

“Obesity and diabetes have become major public issues, andthey are intimately linked with preventable causes of cancer.We’re moving aggressively in this area to educate and provideinformation and recommendations for practicing oncologists andpatients,” Dr. Szabo said.

Committee member Jennifer A. Ligibel, MD, of Dana-Farber CancerInstitute, believes that oncologists have a crucial role to play inencouraging patients to make healthy choices about energy balance, butnotes that more research and improved patient access to information andresources are also paramount. “The Livestrong Foundationpartnered with the YMCA to create one of the first national programsfor increased activity for patients with cancer. We need similarprograms in weight loss and dietary counseling. We need real researchto determine what human behaviors make a difference after a cancerdiagnosis and what changes are most effective,” she said.

The current lack of clear, direct guidance on energy balance and cancerprevention can lead some patients to eschew the pathway of increasedphysical activity and a healthy diet for unproven—andpotentially dangerous—supplements.

“There is so much misinformationout there,” Dr. Ligibel said. “Eating a diet withlots of fruits and vegetablesis not as exciting as the promise offixing everything with a pill. We needto provide guidance to oncologists about some of these supplements sothey can counsel their patients: what’s safe,what’s not, and what the side effects are.”

Cancerscreening, risk assessment, andmanagement
The Cancer Prevention Committee is actively working to provide guidanceand information in the areas of cancerscreening and overall cancer risk assessment and management,particularly as it relates to hereditary cancer risk.

The Cancer Prevention Committee has supported the Clinical PracticeGuidelines Committee in creating recommendations related to screeningfor specific cancers, a crucial aspect of a cancer prevention program.In 2012, ASCO published two new screening guidelines and relatedclinical tools:

A guideline has also been published on chemoprevention for breastcancer (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 Committeehas played a leadership role in educating the oncology community formore than a decade. In 2012, a conference on family history wasorganized, with the purpose of defining the minimum family history thatoncologists should assess. This stemmed from data collected from QOPIon genetic counseling practices, which demonstrated that whileoncologists often document a patient’s first-degree familyhistory of cancer, many practices do not routinely assess the historyof second-degree relatives or the age at which family members werediagnosed with cancer.

This in-depth family history “is necessary to determine thepatient’s risk of developing a second cancer,” saidMarie Wood, MD, of the University of Vermont and a member of the CancerPrevention Committee. “Right now there are no standards forcollecting this information.” The committee plans to definethe minimum standards based on expert consensus to assist oncologistsin providing better counseling on individual cancer risk and preventionstrategies.

In May, a 1.5-day seminar on “Genetics and Genomics for the Practicing Clinician” will be offered as one ofASCO’s Pre-Annual Meeting Seminars. The course will covertumor and germ-line topics, discuss the variety of tests available tothe clinician, and share best practices for administering genetictesting.

The challenges of cancer prevention are real, and additional researchis required in many areas. But the benefits of investing time andresources in prevention are significant. “When one combineslifestyle interventions, judicious screening, and possiblypharmacologic interventions, the potential to make a difference in thecancer burden is huge,” Dr. Szabo said. “The fieldof prevention offers enormous opportunity to change cancer care in apositive way.”

By Virginia Anderson, SeniorWriter/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 oftheir own health and struggle to make healthy choices when stressesfrom work, family, and other commitments pile up. It can feelhypocritical to encourage a patient to make a significant lifestylechange when the physician knows that he or she isn’t themodel of healthy behavior. ASCO Connection spoke with two oncologistson ASCO’s Cancer Prevention Committee who stress positivelifestyle choices to their patients and use their own challenges andexperiences as a starting point for the conversation.

Cancer Prevention Committee ChairEva M. Szabo, MD, resolved to improve her health several years ago whenshe first began an exercise regimen, but it was not until her childrenwent off to college in September 2012 that she could devote sufficientenergy to exercise and diet to meet her goals for weight loss.

“I aim for four to five workouts per week, and although Idon’t manage that every week, I’ve achieved thisgoal most of the time,” she said. “I’vegone on a diet and have lost some weight. I’m making aneffort to live what I’m preaching to others, and the areawhere I’m making the biggest change is in my energy balance,for several reasons—cardiovascular as well as cancerprevention.”

Dr. Szabo admits that prior to embarking on a new, healthier lifestyle,she didn’t exercise much for most of her adult life andthought a “runner’s high was a myth.” Nowshe says that personal experience has taught her that “onceyou 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,” sheadmits that a workout and managing a healthy diet are harder to squeezein to her schedule than they used to be.

“I have young children, a full-time job, andthere’s a lot of juggling that goes on,” Dr.Ligibel said. “I do exercise regularly, but it’sthree days a week instead of the six it used to be. And there are dayswhen I have pizza for dinner because I’m too tired to makesomething else, and that’s what the kids arehaving.”

Dr. Ligibel doesn’t believe these personal challenges make itdifficult to talk to patients about their lifestyle choices; ifanything, it makes her more empathetic to their setbacks.

“I think my own need for a balance makes me better atrelating to some of the challenges my patients have,” shesaid. “Before, when I was biking 70 miles a week, it wassometimes hard for me to understand, ‘Well what do you meanyou can’t get in a half-hour walk at lunchtime?’”

Now, when Dr. Ligibel speaks to a patient about increasing activity orweight loss, she is able to give practical tips. For example, if apatient has small children, she might suggest buying a double joggingstroller and going out for a run with the kids after work. If thatdoesn’t work, she may recommend a commercial weight-lossprogram.

“Give people very clear instructions.Not—‘This is what you should do,’ but‘This is how you do it,’” Dr. Ligibelsaid. “There’s no blaming or implying that thepatient didn’t try hard enough. The focus is on what we cando about it now.”

Share your healthy lifestylestories or challenges in the comments below.

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