New Lung Cancer PowerPoint

Lung Cancer Prevention and Control This activity is accredited for up to 1 hour of AMA PRA Cat. 1 credit. To obtain CME credit for this module, complete and print out the online evaluation and return with $10 to TMA/POEP, 401 West 15th Street, Austin, TX 787011680. Objectives After completion of this module, the physician will be able to: 1. Describe the demographics of the lung cancer epidemic. 2. Identify risk factors for lung cancer. 3. Identify patients’ risk for lung cancer through their history, physical examination, and laboratory tests. 4. Assess the costs and benefits of screening for asymptomatic lung cancer. Objectives (continued) After completion of this module, the physician will be able to: 5. 6. 7. Describe the staging of lung cancer and the importance of early detection. Describe the role of physician intervention and counseling in smoking cessation. Describe the limitations of behavioral and pharmacological aids for smoking cessation. Describe activities that can be conducted in the office setting to support patient smoking cessation 8. The Lung Cancer Epidemic 180000 170000 Quantity (Est.) (Est.) 160000 150000 140000 1989 1990 1991 1992 1993 1994 1995 1997 1998 Year (Est.) (Est.) Cases Death Source: American Cancer Society, Cancer Facts & Figures, 1998. 20-Year Trend in Lung Cancer Death Rates* *Age Adjusted (per 100,000) 80 70 60 50 40 30 20 10 0 1972-1974 1992-1994 Male Female Source: American Cancer Society, Cancer Facts & Figures, 1998. Risk Factors for Lung Cancer Tobacco smoke - active and passive  Environmental or occupational carcinogens, including radon gas  Age  Family history  Dietary history  General population  If what happened on your inside happened on your outside, would you still smoke? Environmental or Occupational Carcinogens Asbestos  Chloromethyl ether  Ionizing radiation  Polycyclic aromatic hydrocarbons  Radon gas  Diet ? ? ? ? ? ? ? ? ? ? ? ? VITAMIN A ? ? ? ? ? ? ? ? ? Development of Lung Cancer Clinical or symptomatic phase  Localized  Regional spread  Disseminated Screening and Early Detection Five-Year Survival Localized lung Extrapulmonary 65% <5% Insufficient evidence to recommend screening high-risk patients Types of Lung Cancer Small cell lung cancer (SCLC)  Non-small cell lung cancer (NSCLC)  – Squamous cell – Adenocarcinoma – Large cell carcinoma Staging Grouping Occult Carcinoma TX Stage 0 (Ca in situ) Stage IA Stage IB Stage IIA Stage IIB T1 T2 T1 T2 T3 TIS N0 N0 N1 N1 N0 M0 M0 M0 M0 M0 N0 M0 Staging Grouping (continued) Stage IIIA T3 T1-3 Any T T4 Any T N1 N2 N3 Any N Any N M0 M0 M0 M0 M1 Stage IIIB Stage IV Non-Small Cell Lung Cancer: Relation of Stage to Usual Treatment Stage 0, I, II IIIA Treatment Surgical resection Surgical resection + X-ray therapy + Chemotherapy X-ray therapy + Chemotherapy + Surgery IIIB IV Supportive care + Chemotherapy + Palliative X-ray therapy Small Cell Lung Cancer Limited Disease Definition: Tumor confined to the thorax and capable of enclosure in a single radiation therapy field Treatment Options:  Combination chemotherapy  Chemotherapy + irradiation  Surgical resection (Stage I) + chemotherapy Source: Cancer Principles & Practice of Oncology, 5th Edition, 1997. Small Cell Lung Cancer Extensive Disease Definition: Tumor not confined to the thorax, or distant metastatic disease Treatment:  Combination chemotherapy Source: Cancer Principles & Practice of Oncology, 5th Edition, 1997. Post Treatment Follow-Up Four-month intervals in the first year Six-month intervals after first year  Clinical history  Physical examination  Chest X-ray  Chemistry group  Hematology group Source: Perez, et al, 1997. Why People Smoke Psychological factors:  Peer pressure/Social acceptability  Stress relief/Felling of well-being Physiological factors:  Nicotine dependence Smoking Cessation Reduces Risk of: Cancers  Lung  Oral  Laryngeal  Esophageal Coronary heart disease Cardiovascular disease, including stroke.  Stomach  Pancreatic  Bladder  Cervical Breaking the Habit Factors that contribute to successful cessation:  Social support  Coping skills  Compliance with nicotine replacement therapy  Control over situations that trigger smoking Situations that trigger smoking and relapse:  Stressful situations  Smoking-related stimuli (others smoking, advertisements, etc.)  Eating, drinking alcohol, celebrations Potential Impact of Physician Advice to Quit Smoking 33 million Smokers seen by physicians each year X 5% Minimum one-year compliance rate ________ 1.65 million Ex-smokers after one year Stages of Change Pre-contemplation  Contemplation  Preparation  Action  Maintenance  Source: Prochaska and DiClemente, 1984. Physician Intervention and Counseling Advantages:  Credibility of physician  Teachable moments  Opportunity to discuss nicotine patch or gum  Potential for follow-up and reinforcement Barriers:  Competition from more acute medical problems  Lack of training  Lack of time  Lack of incentive Six Steps to Effective Intervention 1. 2. 3. 4. 5. 6. Involve the entire staff. Appoint a smoking cessation coordinator. Create a smoke-free environment. Identify all smoking patients (chart sticker). Develop smoking cessation plans for every patient who smokes or lives with a smoker. Provide follow-up care. Creating a Smoke-Free Office Environment Establish a smoke-free office.  Display signs, such as “This is a smokefree zone.”  Have smoking cessation materials available.  Stock magazines in the waiting room that don’t advertise tobacco.  Apply Familiar Medical Principles Assess  Diagnose  Treat or refer  Follow-up  Ask 1. 2. 3. 4. 5. Do you smoke? If so, how many cigarettes do you smoke in a typical day? How long have you smoked cigarettes? Do you smoke within 30 minutes of arising in the morning? Do you awaken to smoke during the night? Pack Years or Risk (# cigarettes per day X 365) R=______________________ X years as a smoker 20 Unique Challenges Patients who…  Don’t want to quit  Want to quit, but not now  Want to smoke fewer cigarettes Long-term intervention without immediate results High relapse rates Clinical Opportunities to Talk About Smoking With Patients Signs/Symptoms  Cough  Shortness of breath   Sputum production Cigarette smell on breath Tests  Auscultation of heart and  Electrocardiography lungs  Total leukocyte counts  Blood pressure  Hematocrit measurements  Blood lipid studies  Carboxyhemoglobin  Pregnancy tests determinations  Pulmonary function  Blood coagulation tests studies Nicotine Withdrawal Syndrome Following abrupt cessation:      Tobacco craving Dysphoria or depressed mood Insomnia Irritability, frustration, or anger Anxiety  Difficulty concentrating  Restlessness  Decreased heart rate  Increased appetite or weight gain Source: DSM-IV, 1994. Managing Nicotine Withdrawal Relaxation training  Exercise  Nicotine replacement therapy  Nicotine Replacement Therapy 21mg Heavy Smoker 15+ cigarettes/day days Moderate Smoker 10-14 cigarettes/day days DOSAGE 14mg 7mg 7 7-14 days 7-10 days 7-14 days 7-10 Light Smoker <10 cigarettes/day days 7-14 Source: POEP’s A’s for Effort: Helping Patients Quit Smoking (1994 edition) Summary Prevention is the key for lung cancer.  Physicians can play an important role in fighting lung cancer by encouraging smoking cessation.  Effective, low-cost interventions are available.  Reading List 1. 2. 3. 4. Glynn TJ, Manley MW. How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. U.S. Department of Health and Human Services, Public Health Service, National Institute of Health, National Cancer Institute. NIH Publication No. 90-3063, 1990. Gritz, ER. Cigarette smoking: The need for action by health professionals. CA:A Cancer Journal for Clinicians, 38:4, July/August 1988. Heinonen OP, et al (The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group). The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. New England Journal of Medicine, 330:15, 1029-1034, 1994. Kottke TE, et al. Attributes of successful cessation interventions in medical practice. Journal of the American Medical Association, 259:2883-2889, 1988. Reading List (continued) 5. 6. 7. 8. 9. Medical news and perspectives: Magazines without tobacco advertising. Journal of the American Medical Association, 226:3099-3102, 1991. Mountain, CF. Revisions in the international system for staging lung cancer. Chest, 111:6, 1710-1717, June, 1997. Naruke T, et al. Comparative study of survival of screendetected compared with symptom-detected lung cancer cases. Seminars in Surgical Oncology, 9:80-84, Wiley-Liss, Inc., 1993. Nesbitt JC, Putnam JB, Walsh GL, Roth JA, Mountain CF. Survival in early-stage non-small cell lung cancer. Annals of Thoracic Surgery, 60:466-472, 1995. Perez EA, Loprinzi CL, Sloan JA, Owens DT, Novotny PJ, Bonner JA. Utility of screening procedures for detecting recurrence of disease after complete response in patients with small cell lung carcinoma. Cancer, 80:676-680, 1997. Reading List (continued) 10. 11. 12. 13. Philips BU, et al. Behavioral prescription writing in smoking cessation counseling: A new use for a familiar tool. Southern Medical Journal, 83:946-953, 1989. Pomerleau OF, Pomerleau CS. Neuroregulators and the reinforcement of smoking: Towards a biobehavioral explanation. Neuroscience & Behavioral Reviews, 8:503-514, 1984. Prochaska JO, DiClemente CC. The Transtheoretical Approach, crossing traditional boundaries of therapy. Dow Jones-Irwin, Homewood, Ill., 1984. Physician Oncology Education Program, Ed. Philips BU. A for Effort: The Doctor’s Role (pockguide), Second Edition, 1998. Reading List (continued) 14. 15. 16. 17. Surveillance for selected tobacco-use behaviors—United States, 1990-1994, Morbidity and Mortality Weekly Report, CDC, U.S. Department of Health and Human Services, 43:SS-3, Nov. 18, 1994. U.S. Department of Health and Human Services. National Cancer Institute Smoking and Tobacco Control Monographs, 1994. U.S. Department of Health and Human Services. How to Help Your Patients Stop Smoking: Trainers’ Guide. U.S. Department of Health and Human Services, Public Health Service, National Institute of Health, no date. Ziegler RG, et al. Importance of alpha-carotene, and other phytochemicals in the etiology of lung cancer. Journal of the National Cancer Institute, 88(9):612-615, May 1, 1996. Other POEP CME Modules         Breast Cancer (and CD-ROM format) Cancer in Special Populations Cervix Cancer Head and Neck Cancer Nutrition and Cancer Risk Reduction Prostate Cancer Skin Cancer Surveillance of Cancer Patients To order these modules in spiral bound or 35mm slide format, contact POEP at POEP@texmed.org or call 800-880-1300, ext. 1672. Evaluation To obtain CME credit for this module, complete and print out the online evaluation and return with $10 to TMA/POEP, 401 West 15th Street, Austin, TX 78701-1680. Return to POEP Online CME