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A TWO-STEP INTERVENTION FOR LUNG CANCER

Illustration by Abigail Goh
By Stephanie Stemmler

Most of us have seen the warnings: Every cigarette pack sold in the United States since 1965 carries a label that identifies the health hazards of smoking. Yet despite these mandated labels and a host of public awareness campaigns in print, broadcast and social media that encourage people to stop smoking, the Centers for Disease Control and Prevention, or CDC, notes that in 2020, more than 30 million people in the U.S. smoke cigarettes. And every day, an estimated 1,600 young people light up a cigarette for the first time.

The 2020 statistics are significant because they represent the first time in 20 years that annual cigarette sales have gone up, not down. While a direct correlation to the COVID-19 pandemic hasn’t been made, the recent increase in the sale of cigarettes, as well as the popularity of other nicotine products such as e-cigarettes, causes concern among health-care specialists who are on the frontlines trying to lower the incidences of lung cancer.

The correlation between smoking and lung cancer is well documented. What’s worrisome is that lung cancer remains the leading cause of cancer deaths in the U.S. According to the American Cancer Society, more people die of lung cancer each year than the number of people who die from breast, colon and prostate cancers combined. This year alone, it estimates 237,000 new lung cancer diagnoses—and 130,000 deaths.

Here’s the conundrum: While health experts say deaths from lung cancer are mostly preventable if people would stop smoking, that’s a complicated proposition. The nicotine in cigarettes is highly addictive. Quitting is really hard to do. And there’s where researchers are focusing their efforts.

Easier said than done

“For years, we’ve had it backwards,” says Li-Shiun Chen, MD, MPH, ScD, psychiatrist at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine. “We were treating the consequences of lung cancer and not addressing the major cause, which is smoking. But cancer-care strategies must include steps that can mitigate or even prevent cancer from occurring. We need to get in front of this disease.”

Chen, a nationally recognized researcher on smoking-cessation strategies, says there’s a “huge misalignment” in what doctors believe and what patients really want. “Many doctors think that patients don’t really want to quit smoking, but the reality is that nearly 70% of adults who smoke say they want to quit,” she says. “Another 20% want to reduce the number of cigarettes they use.”

The discrepancy Chen points out was vividly apparent during a recent focus group, during which she, colleagues and patient participants searched for ways to engage people in smoking cessation programs. “We had a patient in one of our groups tell us: ‘Everyone asks me about smoking, but no one offers anything to help me quit,’” recalls Chen. “Clearly, it’s not enough for a doctor or nurse to tell a patient that they should quit, then make a checkmark on a medical-history form. We need to offer proven smoking-cessation treatment options, just like we do with cancer or any life-shortening condition.”

In 2017, as part of the National Cancer Institute’s (NCI) Cancer Moonshot program, the Cancer Center Cessation Initiative was established to help cancer centers across the country conduct research, and create and implement tobacco-cessation treatment programs that were proven to work. Toward that end, in a clinical research study, Chen and psychiatrist Laura Bierut, MD; implementation scientist Alex Ramsey, PhD; medical oncologist Ramaswamy Govindan, MD; and other Washington University researchers at The Alvin J. Siteman Cancer Center at Barnes Jewish Hospital and Washington University School of Medicine used electronic medical records (EMRs) to identify patients with cancer who were smokers. Then, whenever one of those patients came in for a clinic visit, they were offered immediate help to quit smoking. The smoking-cessation options offered included:

  • Immediate referral for free, text-based counseling from the NCI
  • Onsite help to download free phone apps to access the NCI’s QuitGuide and quitSTART smoking-cessation platforms
  • FDA-approved medications to stop or reduce smoking
  • Referral to a free smoking-cessation program

In short, people were offered several point-of-care treatment programs that were easily accessible. The result? The number of patients receiving smoking-cessation treatment increased from 2% at the start of the program to nearly 30%. Overall, about one-third of patients participating in the program stopped smoking. The findings were published in the May 2022 issue of the Journal of the National Comprehensive Cancer Network.

Of significance, the researchers also found that those who quit smoking after a cancer diagnosis doubled their survival rate and lowered their risk of recurrence, no matter the severity of the cancer. The early success of Siteman’s point-of-care tobacco treatment program has prompted health-care leaders to deploy the program at many other hospitals within BJC HealthCare, the network to which Barnes-Jewish Hospital belongs. Those working within the program will share their successes with other academic health centers nationwide, and they will work to reach people treated in specialty clinics, primary care practices and other health-care settings.

“We have to be non-judgmental during these conversations at the point of care,” notes Chen. “Smoking is not a weakness, and it’s not a person’s fault if they can’t stop smoking on their own. Cigarette-smoking is an addiction. We need to address it, and treat it with compassion.”

Screening for lung cancer

In addition to its focus on effective smoking-cessation programs, Siteman Cancer Center offers screenings for lung cancer. Lung cancer can go undetected until it reaches an advanced stage; screening can reveal a problem before symptoms are noticed. And early detection is one of the keys to better outcomes.

In 2011, results from the National Lung Screening Trial—to date the largest clinical trial of its kind in the U.S.—found that low-dose CT scans were effective at identifying small, early-stage lung tumors. That study led the National Comprehensive Cancer Network to issue new guidelines that encourage screening for those at risk of developing lung cancer because they are 50 years old or older and have a smoking history of a 20-pack year or greater. (See the sidebar below for a definition of a 20-pack year and for information about screening eligibility.)

David Gierada, MD, Washington University radiologist at Siteman Cancer Center, served as a principal investigator for the National Lung Screening Trial. He notes: “It’s too early to tell what the significant impact of low-dose CT screening has been because it didn’t become recommended clinical practice until 2015. Though the proportion of eligible persons who get screened has been increasing, it’s still very low.”

Early findings from the trial, however, suggest that a CT scan can reduce mortality from lung cancer by 20%, simply because it can identify the disease at an early stage. Anne Stilinovic, RN, BSN, supervisor of the Lung Cancer Screening Program at Siteman Cancer Center, is one of the center’s three nurse navigators who guide people through the screening program and offer referrals to thoracic surgeons and pulmonologists, if needed. In 2021, the program screened 2,880 people for lung cancer. Of those who were diagnosed with cancer, 70% were found to be in stage 1—the earliest stage of the disease.

To be most effective, lung cancer screening should be done annually for at least three years. “The test by itself takes one to two minutes,” says Stilinovic. “It’s non-invasive: no needles, no contrast dye, no prep work. Radiologists can detect lung nodules as small as 1 mm in size with a CT scan.”

The challenge, she says, is that 60% to 75% of people who undergo screening will have a lung nodule detected. For the person screened, that can mean a lot of anxiety and worry: Is the nodule benign or cancerous? Says Stilinovic: “Of 100 persons screened for the first time, about 15 have a false alarm. Lung nodules are common as people age; even those who have never smoked can develop them.” But, she adds, “a nodule also can be an early cancer. If something suspicious is detected, we make a referral for additional testing.”

For those requiring a follow-up visit with a surgeon, the recommendation may be watchful waiting followed by another appointment in six months. In some cases, a PET scan or tissue biopsy might be recommended. It’s important to note that not all lung cancers are detected with low-dose CT screening, but it currently is the only screening tool shown to lower the risk of death from the disease. The screening may also identify coronary artery calcifications and other conditions in the neck or upper abdomen, which would prompt further testing.

Ongoing research is focused on identifying barriers that might prevent people from getting screened, as well as on opportunities to increase the number of people who choose screening. Other investigations are focused on developing better guidelines for managing the different types of lung nodules found during screening. Washington University researchers at Siteman also are participating in a clinical trial called I-STEP—Increasing Screening through Engaging Primary Care Providers—aimed at improving awareness among primary care physicians of the benefits of screening.

Says Gierada: “The death rate from lung cancer has been decreasing for more than 20 years, even before the advent of screenings, and it parallels an earlier drop in smoking rates. Therefore, efforts to promote quitting and keep people from starting to smoke have paid off. I think expanding the screening eligibility criteria, broadening physician and public awareness and increasing access and availability of smoking cessation programs are critical to lowering the mortality rate even further.”

Lung Cancer Screening: Who’s Eligible?

Most private insurance companies and Medicare will cover the cost of lung cancer screenings in high-risk patients with a long history of smoking. Early in 2022, Medicare expanded the eligibility age to get more people screened.

You qualify for a screening if you have a referral from your primary care physician and if you:

  • are between the ages of 50 and 80 (Medicare covers age 50-77) AND
  • have a smoking history of 20 pack-years* or more, OR
  • are a former heavy smoker who quit less than 15 years ago

*To determine a 20-pack year: Multiply the average number of packs smoked per day times the years smoked:

  • 1 pack per day for 20 years = a 20-pack year
  • 3/4 pack per day for 30 years = a 20-pack year
  • 1/2 pack per day for 40 years = a 20-pack year

According to the American Cancer Society, this is what happens after someone quits smoking:

20 minutes after quitting:
Heart rate and blood pressure drop.

A few days after quitting:
Carbon monoxide level in the blood drops to normal.

2 weeks to 3 months after quitting:
Circulation improves and lung function increases.

1 to 12 months after quitting:
Coughing and shortness of breath decrease.
Tiny hair-like structures (called cilia) that move mucus out of the lungs start to regain normal function, increasing their ability to handle mucus, clean the lungs and reduce the risk of infection.

1 to 2 years after quitting:
Risk of heart attack drops dramatically.

5 to 10 years after quitting:
Risk of cancers of the mouth, throat and larynx is cut in half.
Risk of stroke decreases.

10 years after quitting:
Risk of lung cancer is about half that of a non-smoker (after 10 to 15 years).
The risk of cancer of the bladder, esophagus, and kidney decreases.

15 years after quitting:
Risk of coronary heart disease is close to that of a non-smoker.


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