Continued smoking with cancer poses significant economic burden


Continued smoking by patients with cancer increases the risk of cancer treatment failure and leads to more than $10,000 of additional costs per patient, on average, for subsequent cancer treatment, according to a new modeling study.

This translates to an additional $3.4 billion in additional cancer treatment costs nationally – costs that may justify better implementation of evidence-based smoking cessation programs in clinical practice, said Graham W. Warren, MD, PhD, of the Hollings Cancer Center at the Medical University of South Carolina, Charleston, and his coinvestigators.

While “drug cost and efficacy have been the primary focus for considering value in cancer care, relatively little consideration has been given to other potentially modifiable factors that could affect cancer treatment costs, including health behaviors such as smoking,” they wrote in JAMA Network Open.

Cara M. Patrucci, MBA, MPH, and Andrew Hyland, PhD, of Roswell Park Comprehensive Cancer Center in Buffalo, N.Y., wrote in an accompanying editorial that the analysis is particularly relevant given the increasing focus on value-based care. “To show the clinical association of smoking with first-line cancer treatment failure in financial terms places continued smoking during cancer treatment alongside surgery and chemotherapy as a significant contributor to cancer treatment costs.”

“Smoking cessation interventions are clinically effective and cost effective and should be part of the treatment plan for every patient with cancer alongside decisions about what surgical procedure, chemotherapy, or radiotherapy is appropriate,” they wrote in the invited commentary.

The model that Dr. Warren and his coinvestigators developed to estimate the economic burden of smoking-associated treatment failures considers several measures: smoking prevalence, expected failure rates of first-line cancer treatment in nonsmoking patients, the odds ratio of first-line cancer treatment failure for smoking patients compared with nonsmoking patients, and the cost of subsequent cancer treatment.

The researchers modeled a wide range of values for each of these measures, based on data from the 2014 Surgeon General’s report on the health consequences of smoking and on the results of multiple studies that have looked at smoking prevalence among patients with various cancer types, for example, as well as expected cure rates across various diagnoses and therapeutic options.

The Surgeon General’s report concluded that smoking among patients with cancer caused an increased risk in cancer-specific mortality (median increased risk of 1.61 across cancer sites and treatments), as well as increased overall mortality and increased risk for a second primary cancer and for toxic effects from cancer treatment.

With modeling conditions of a 30% expected treatment failure rate among nonsmoking patients, 20% smoking prevalence, 60% increased risk of failure of first-line cancer treatment, and a mean cost of treating first-line cancer treatment failure of $100,000, the additional incremental cost per 1,000 total patients (smokers and nonsmokers) was estimated to be $2.1 million – or an additional mean cost per smoking patient of $10,678.

Extrapolating these outcomes to 1.6 million patients with a cancer diagnosis annually indicates there is “a potential $3.4 billion incremental cost of treating cancer failures associated with continued smoking among patients with cancer in the U.S. each year,” wrote Dr. Warren, professor and vice chairman for research in radiation oncology at MUSC, and his coinvestigators.

The cost estimates are very likely conservative, they noted, since the model did not consider the costs of increased cancer treatment toxicity, the treatment of other smoking-related diseases, or end-of-life care.

The new model can be used to estimate outcomes across a breadth of potential cancer conditions, treatment modalities, and associated costs. In patients with lung cancer, they noted, addressing smoking-attributable failure of chemotherapy may require second-line cytotoxic or biologic systemic therapy or immunotherapy, with or without palliative conformal radiotherapy.

Smoking rates, they also noted, are highly dependent on geographic factors and vary across cancer type. Smoking rates of 50% or more have been reported in patients with lung cancer, while lower smoking rates have been reported among patients with breast or prostate cancer.

An analysis of 224 patients with lung cancer who smoked and were enrolled in a telephone-based cessation program reported a 44% reduction in overall mortality associated with quitting smoking

Research has shown that smoking cessation after a cancer diagnosis can improve survival, the researchers wrote. An analysis of 224 patients with lung cancer who smoked and were enrolled in a telephone-based cessation program reported a 44% reduction in overall mortality associated with quitting smoking (J Thorac Oncol. 2015;10[7]:1014-9). And in another study, cessation of smoking after treatment for small cell lung cancer was associated with a reduction in mortality of 41%, compared with continued smoking (Lung Cancer. 2010;67[2]:221-6).

Surveys have shown, however, that most oncologists do not provide smoking cessation support to patients with cancer, the researchers wrote. Ms. Patrucci and Dr. Hyland echoed these concerns, writing that smoking cessation “fails to attract the attention of systems and clinicians who … operate within the constraints of an increasingly tight financial environment.”

Surveys have shown, however, that most oncologists do not provide smoking cessation support to patients with cancer

Insurance coverage for smoking cessation is limited, they wrote, and “tends to disproportionately favor medical interventions, such as smoking cessation medications, compared with evidence-based behavioral interventions.”

However, the tide may be turning somewhat in oncology. The National Cancer Institute launched an initiative in 2017 as part of the NCI Cancer Moonshot program to help NCI-designated cancer centers implement sustainable evidence-based smoking cessation programs that “routinely address tobacco cessation with cancer patients.”

Future research, according to Ms. Patrucci and Dr. Hyland, could delve into the nuances of smoking cessation in patients with cancer. For example, they wrote, when is the best time for smoking cessation – before, during, and/or after treatment? And how does the use of other nicotine-containing products, such as nicotine patches or e-cigarettes, affect outcomes and costs?

Coauthor Elizabeth Garrett-Mayer, PhD, reported receiving grants from the National Institutes of Health during the conduct of the study, and coauthor Michael Cummings, PhD, MPH, reported receiving personal fees from Pfizer during the conduct of the study and from various plaintiff law firms outside of the submitted work.

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