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The problem of cigarette smoking in radiotherapy for cancer in the head and neck
Clinical Oncology (1992) 4:214-216 © 1992 The Royal College of Radiologists
Clinical Oncology
Original Article The Problem of Cigarette Smoking in Radiotherapy for Cancer in the Head and Neck C. Des Rochers, S. Dische and M. I. Saunders Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK
Abstract. Smoking cigarettes during radiotherapy prolongs the period of reaction and may reduce the chance of cure. Of a group of 48 patients with advanced head and neck cancer 35 were smoking at the time of diagnosis, but 17 were persuaded to stop, although 7 relapsed later. Interviews conducted in 35 of the 48 patients revealed the problems which must be overcome if such patients are to cease smoking. Keywords: Cigarette smoking; Head and neck cancer; Radiotherapy; Treatment reactions
INTRODUCTION Radiotherapy given to patients for locally advanced cancer in the head and neck region is dose-limited by both acute and late reactions in normal tissues. Although acute reactions are dominantly influenced by dose, time and volume factors, there are others which may affect their severity and duration. In accelerated radiotherapy, using the C H A R T regime, we have shown that continued cigarette smoking can almost double the duration of mucositis in patients with advanced head and neck cancer when comparison is made with those who gave up smoking prior to treatment [1]. Further, we have noted that even when healing occurs after a prolonged period of acute reaction there may be greater long-term changes in the oral mucosa and so smoking may increase the severity of late changes following a course of radiotherapy [1]. In conventionally fractionated radiotherapy, severe and prolonged reactions may extend overall treatment time and so, in turn, lead to reduced tumour control [2]. Browman et al. [3] reported a reduced tumour response and survival among patients who continued to smoke during a conventionally fractionated course of radiotherapy, Correspondence and offprint request to: Professor S. Dische, Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Veron Hospital, Northwood, Middlesex HA6 2RN, UK.
but there was, in their series, no increase in the number of interruptions of treatment in smokers and a biological explanation was favoured. To all the health hazards of cigarette smoking we must, therefore, include increased morbidity and possibly impaired tumour response to radiotherapy when given for tumours in the head and neck. We have found that cessation of cigarette smoking before C H A R T has an immediate effect, reducing the morbidity of treatment, but despite vigorous education of patients concerning this, many continue to smoke and do so through treatment, regardless of the presence of advanced tumours and radiation reactions [1]. A series of patients who have received radiotherapy using C H A R T have been studied to determine their attitude to cigarette smoking.
METHODS Between January 1985 and December 1988, a total of 92 patients with tumours sited in the head and neck region were treated with C H A R T [4]. Of these, 48 were well, free of disease, and attending for regular follow-up in January 1990; they comprised 37 males and 11 females, with a mean age of 64 years (range 25-82). The sites of the primary tumour were in the oral cavity, oropharynx, laryngopharynx and larynx, but they also included four with extensive carcinomas of the columella where the treatment field extended into the oral cavity. Thirty-eight of the 48 presented with tumours which were in the T3 or T4 category; 35 consented to attend for a special interview which was conducted according to the guidelines of a questionnaire. Smokers were asked if they had ever wished to stop and, if so, had they ever sought help and advice, and also why they had not stopped. Those who had already stopped smoking were asked about the factors which led to their stopping, and further questioned on whether any individual person had influenced their decision and whether they had obtained any help or advice.
Cigarette Smoking in Radiotherapy for Cancer in the Head and Neck
215
RESULTS There were two patients who had never smoked; of the 46 remaining patients, 11 had ceased the habit at least 1 year before the diagnosis of cancer and 35 were actively smoking at the time of diagnosis. Seventeen then stopped before radiotherapy commenced, while 18 carried on throughout their treatment, even though they were strongly advised not to do so. One of these patients, despite smoking all the way through radiotherapy and the period of reaction, later abandoned the habit completely. Of the 17 who stopped immediately before treatment, seven resumed, some even before radiation reactions had settled, leaving 10 who had maintained their abstinence up to the time of interview. It follows that despite the diagnosis of cancer and subsequent intensive treatment, 24 of the 35 who were smoking at the time of diagnosis were continuing to do so at the time of the review. The other 24 patients included two who had never smoked, 11 who had given up at least a year before the diagnosis had been made, 10 who stopped between the time of diagnosis and the beginning of radiotherapy and one who, although smoking throughout treatment, gave up at a later time. There were 19 patients who were still smoking at the time of interview and 14 of these said that they did so because it gave satisfaction, enjoyment or comfort. Four said it eased stress and only the final patient confessed to being addicted to a practice that gave him no pleasure. Of the 19, 10 responded that at no time had they wished to stop, but nine expressed a desire to stop. However, despite attempts, they had been unable to do so. Six of these nine had made a real attempt to do so, enlisting a special method to aid them. However, they were unsuccessful in maintaining abstinence for more than a few days (Table 1). Of the 16 patients interviewed who were able to cease the habit (Table 1), 8 responded that the knowledge of their cancer really prompted them to do so. Other smoking-related illnesses (bronchitis, angina, emphysema) prompted five patients and three gave other reasons - in two cases family pressure, and in one financial hardship. Ten of the patients identified particular individuals who influenced their decision to discontinue; in six, it was Table 1. Methods employed to help discontinue smoking by 35 patients consenting to interview
Special method
Those who continued smoking
Those who discontinued smoking
Group counselling Hypnotherapy Acupuncture Nicotine chewing gum Dummy cigarettes Special filters Nieobrevine capsules None
0 1 0 1 2 0 2 13
0 0 0 2 0 0 0 14
Total
19
16
OF DIAGNOSIS 3~
I
I
CONTINUED T"ROUG"I
STOPPED LATER
BEFORE DIAGNOSIS
11
STOPP~D'~EFORE
RESUMED
24
NOT SMOKING AT
24
j
Fig. 1. Patients with advanced head and neck cancer successfully treated with CHART.
the consultant in oncology concerned with the management of their tumour, in two it was the general practitioner and in two it was a member of their family.
DISCUSSION Only limited success in stopping smoking prior to radiotherapy was obtained in our patients with head and neck cancer. This was despite the knowledge that they were suffering from a smoking-related tumour and the close attendance given them by doctors and nurses. This is unfortunately in line with the general experience with similar groups of smokers [3]. Well-Jenkins [5] considered that most smokers have two compulsions which require attention: the addiction itself and the habit pattern linked to physical rituals and emotional situations. In addition, patients presenting with advanced head and neck cancer often present problems that have not only contributed to the production of the tumour, but also affect their ability to alter their lifestyle. Many are elderly with a long history of tobacco addiction which may also have induced other vascular and pulmonary smoking-related illnesses, so reducing their wellbeing and their motivation. Many have also chronically abused alcohol and may suffer some associated mental impairment. Poor social circumstances are common and many live alone, lacking family and community support. Modest or reduced intelligence may limit their understanding of the situation. All these problems contribute to the difficulty in persuading them to stop smoking. Of the 35 patients interviewed in this study, one patient was over the age of 80, only eight were under
216
60 years old, while 26 were between 60 and 79 years of age. Ten of the 35 patients lived alone, while 6 others were living with an elderly and unwell spouse. These problems, however, should not discourage attempts to help educate, motivate and support these patients in their attempts to cease smoking. The knowledge that by doing so they can decrease complications from therapy, and thus improve their tolerance to treatment and their quality of life, may be sufficient for many to quit. Knudsen et al. [6] have shown the value to lung cancer patients of ceasing to smoke. In a report from the Royal College of Physicians in (1983) [7] it was stressed that the health care professions have the greatest responsibility and potential for action. Eraker et al. [8] found that during an illness the smoker is often ready to stop and that, in those who stopped smoking, 50% were influenced by the clinician; health reasons were considered to be the motivating factor to stop in 81%. They suggest that clinicians should provide advice about smoking as a regular part of every consultation. The patient attending for radical radiotherapy for head and neck cancer is seen regularly by a doctor at a minimum frequency of once weekly for 6 weeks or more and also daily by nurses and radiographers. This should provide ample opportunity for intensive teaching and support. A responsibility extends to all health care workers to set an example and encourage patients not to smoke. They should not smoke themselves, and particularly never smoke in the presence of patients. A number of surveys [9, 10] have shown a high prevalence of smoking among nurses, as great as 40% in a survey performed in 1985. A nurse who smokes herself will find it difficult to persuade a patient to quit. As so much work of a cancer treatment centre is directed to the care of patients whose turnouts are smoking-related, it follows that such a centre should take a leading role in the anti-smoking campaign. Ho [11] suggests that with a conducive atmosphere
C. Des Rochers et al.
patients should leave hospital cured of their addiction, as well as their disease. Staff should adopt a positive attitude and actively participate in measures to help reduce smoking and also ensure a ban on tobacco sales within hospital premises. A member, or members, of the staff at cancer treatment centres could be specially trained to assist patients, as well as colleagues, to give up this pernicious habit.
Acknowledgements. We wish to acknowledge the continued support of the Cancer Research Campaign and to thank Mrs Eileen Davies for the preparation of the manuscript.
References 1. Rugg T, Saunders MI, Dische S. Smoking and mucosal reactions to radiotherapy. Br J Radiol 1990, 63:554-6. 2. Maciejewski B, Preuss-Bayer G, Trott K-R. The influence of the number of fractions and of the overall treatment time on local control and late complication rate for squamous cell carcinoma of the larynx. Int J Radiat Oncol Biol Phys 1983; 9:321-8. 3. Browman GP, Wong C, Hodson I, et al. Reduced turnout response and survival among patients with head and neck cancer who continue to smoke during radiation therapy. Int J Rad Oncol Biol Phys 1990; 19 Supp 1:143. 4. Saunders MI, Dische S, Grosch EJ, et al. Experience with CHART. Int J Radiat Oncol Biol Phys 1991; 21:871-8. 5. Wells-Jenkins M. Nicotine addiction treated by acupuncture: Acupuncture in medicine. Br Med Acupuncture Soc J 1986; III:l 1. 6. Knudsen N, Schulman S, Fowler R, et al. Why bother with stop-smoking education for lung cancer patients? Oncol Nurs Forum 1984; 11(3):30-3. 7. Royal College of Physicians Report. Health or Smoking. London: Pitman, 1983:126. 8. Eraker SA, Becket MH, Strecher VJ. Smoking behavior, cessation, techniques and the health decision model. Am J Med 1985; 78:817-25. 9. Ferguson P, Small WP. Further study of the smoking habits of hospital nurses. Health Bull 1985; 43:13-8. 10. Laurent C. Resolutions - up in SMOKE. Nuts Mirror 1985; 160:30. 11. Ho AMH. Reducing smoking in hospitals: a time for action. JAMA 1985; 253:299%3000.
Received for publication August 1991 Accepted October 1991
Clinical Oncology
Original Article The Problem of Cigarette Smoking in Radiotherapy for Cancer in the Head and Neck C. Des Rochers, S. Dische and M. I. Saunders Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK
Abstract. Smoking cigarettes during radiotherapy prolongs the period of reaction and may reduce the chance of cure. Of a group of 48 patients with advanced head and neck cancer 35 were smoking at the time of diagnosis, but 17 were persuaded to stop, although 7 relapsed later. Interviews conducted in 35 of the 48 patients revealed the problems which must be overcome if such patients are to cease smoking. Keywords: Cigarette smoking; Head and neck cancer; Radiotherapy; Treatment reactions
INTRODUCTION Radiotherapy given to patients for locally advanced cancer in the head and neck region is dose-limited by both acute and late reactions in normal tissues. Although acute reactions are dominantly influenced by dose, time and volume factors, there are others which may affect their severity and duration. In accelerated radiotherapy, using the C H A R T regime, we have shown that continued cigarette smoking can almost double the duration of mucositis in patients with advanced head and neck cancer when comparison is made with those who gave up smoking prior to treatment [1]. Further, we have noted that even when healing occurs after a prolonged period of acute reaction there may be greater long-term changes in the oral mucosa and so smoking may increase the severity of late changes following a course of radiotherapy [1]. In conventionally fractionated radiotherapy, severe and prolonged reactions may extend overall treatment time and so, in turn, lead to reduced tumour control [2]. Browman et al. [3] reported a reduced tumour response and survival among patients who continued to smoke during a conventionally fractionated course of radiotherapy, Correspondence and offprint request to: Professor S. Dische, Marie Curie Research Wing, Mount Vernon Centre for Cancer Treatment, Mount Veron Hospital, Northwood, Middlesex HA6 2RN, UK.
but there was, in their series, no increase in the number of interruptions of treatment in smokers and a biological explanation was favoured. To all the health hazards of cigarette smoking we must, therefore, include increased morbidity and possibly impaired tumour response to radiotherapy when given for tumours in the head and neck. We have found that cessation of cigarette smoking before C H A R T has an immediate effect, reducing the morbidity of treatment, but despite vigorous education of patients concerning this, many continue to smoke and do so through treatment, regardless of the presence of advanced tumours and radiation reactions [1]. A series of patients who have received radiotherapy using C H A R T have been studied to determine their attitude to cigarette smoking.
METHODS Between January 1985 and December 1988, a total of 92 patients with tumours sited in the head and neck region were treated with C H A R T [4]. Of these, 48 were well, free of disease, and attending for regular follow-up in January 1990; they comprised 37 males and 11 females, with a mean age of 64 years (range 25-82). The sites of the primary tumour were in the oral cavity, oropharynx, laryngopharynx and larynx, but they also included four with extensive carcinomas of the columella where the treatment field extended into the oral cavity. Thirty-eight of the 48 presented with tumours which were in the T3 or T4 category; 35 consented to attend for a special interview which was conducted according to the guidelines of a questionnaire. Smokers were asked if they had ever wished to stop and, if so, had they ever sought help and advice, and also why they had not stopped. Those who had already stopped smoking were asked about the factors which led to their stopping, and further questioned on whether any individual person had influenced their decision and whether they had obtained any help or advice.
Cigarette Smoking in Radiotherapy for Cancer in the Head and Neck
215
RESULTS There were two patients who had never smoked; of the 46 remaining patients, 11 had ceased the habit at least 1 year before the diagnosis of cancer and 35 were actively smoking at the time of diagnosis. Seventeen then stopped before radiotherapy commenced, while 18 carried on throughout their treatment, even though they were strongly advised not to do so. One of these patients, despite smoking all the way through radiotherapy and the period of reaction, later abandoned the habit completely. Of the 17 who stopped immediately before treatment, seven resumed, some even before radiation reactions had settled, leaving 10 who had maintained their abstinence up to the time of interview. It follows that despite the diagnosis of cancer and subsequent intensive treatment, 24 of the 35 who were smoking at the time of diagnosis were continuing to do so at the time of the review. The other 24 patients included two who had never smoked, 11 who had given up at least a year before the diagnosis had been made, 10 who stopped between the time of diagnosis and the beginning of radiotherapy and one who, although smoking throughout treatment, gave up at a later time. There were 19 patients who were still smoking at the time of interview and 14 of these said that they did so because it gave satisfaction, enjoyment or comfort. Four said it eased stress and only the final patient confessed to being addicted to a practice that gave him no pleasure. Of the 19, 10 responded that at no time had they wished to stop, but nine expressed a desire to stop. However, despite attempts, they had been unable to do so. Six of these nine had made a real attempt to do so, enlisting a special method to aid them. However, they were unsuccessful in maintaining abstinence for more than a few days (Table 1). Of the 16 patients interviewed who were able to cease the habit (Table 1), 8 responded that the knowledge of their cancer really prompted them to do so. Other smoking-related illnesses (bronchitis, angina, emphysema) prompted five patients and three gave other reasons - in two cases family pressure, and in one financial hardship. Ten of the patients identified particular individuals who influenced their decision to discontinue; in six, it was Table 1. Methods employed to help discontinue smoking by 35 patients consenting to interview
Special method
Those who continued smoking
Those who discontinued smoking
Group counselling Hypnotherapy Acupuncture Nicotine chewing gum Dummy cigarettes Special filters Nieobrevine capsules None
0 1 0 1 2 0 2 13
0 0 0 2 0 0 0 14
Total
19
16
OF DIAGNOSIS 3~
I
I
CONTINUED T"ROUG"I
STOPPED LATER
BEFORE DIAGNOSIS
11
STOPP~D'~EFORE
RESUMED
24
NOT SMOKING AT
24
j
Fig. 1. Patients with advanced head and neck cancer successfully treated with CHART.
the consultant in oncology concerned with the management of their tumour, in two it was the general practitioner and in two it was a member of their family.
DISCUSSION Only limited success in stopping smoking prior to radiotherapy was obtained in our patients with head and neck cancer. This was despite the knowledge that they were suffering from a smoking-related tumour and the close attendance given them by doctors and nurses. This is unfortunately in line with the general experience with similar groups of smokers [3]. Well-Jenkins [5] considered that most smokers have two compulsions which require attention: the addiction itself and the habit pattern linked to physical rituals and emotional situations. In addition, patients presenting with advanced head and neck cancer often present problems that have not only contributed to the production of the tumour, but also affect their ability to alter their lifestyle. Many are elderly with a long history of tobacco addiction which may also have induced other vascular and pulmonary smoking-related illnesses, so reducing their wellbeing and their motivation. Many have also chronically abused alcohol and may suffer some associated mental impairment. Poor social circumstances are common and many live alone, lacking family and community support. Modest or reduced intelligence may limit their understanding of the situation. All these problems contribute to the difficulty in persuading them to stop smoking. Of the 35 patients interviewed in this study, one patient was over the age of 80, only eight were under
216
60 years old, while 26 were between 60 and 79 years of age. Ten of the 35 patients lived alone, while 6 others were living with an elderly and unwell spouse. These problems, however, should not discourage attempts to help educate, motivate and support these patients in their attempts to cease smoking. The knowledge that by doing so they can decrease complications from therapy, and thus improve their tolerance to treatment and their quality of life, may be sufficient for many to quit. Knudsen et al. [6] have shown the value to lung cancer patients of ceasing to smoke. In a report from the Royal College of Physicians in (1983) [7] it was stressed that the health care professions have the greatest responsibility and potential for action. Eraker et al. [8] found that during an illness the smoker is often ready to stop and that, in those who stopped smoking, 50% were influenced by the clinician; health reasons were considered to be the motivating factor to stop in 81%. They suggest that clinicians should provide advice about smoking as a regular part of every consultation. The patient attending for radical radiotherapy for head and neck cancer is seen regularly by a doctor at a minimum frequency of once weekly for 6 weeks or more and also daily by nurses and radiographers. This should provide ample opportunity for intensive teaching and support. A responsibility extends to all health care workers to set an example and encourage patients not to smoke. They should not smoke themselves, and particularly never smoke in the presence of patients. A number of surveys [9, 10] have shown a high prevalence of smoking among nurses, as great as 40% in a survey performed in 1985. A nurse who smokes herself will find it difficult to persuade a patient to quit. As so much work of a cancer treatment centre is directed to the care of patients whose turnouts are smoking-related, it follows that such a centre should take a leading role in the anti-smoking campaign. Ho [11] suggests that with a conducive atmosphere
C. Des Rochers et al.
patients should leave hospital cured of their addiction, as well as their disease. Staff should adopt a positive attitude and actively participate in measures to help reduce smoking and also ensure a ban on tobacco sales within hospital premises. A member, or members, of the staff at cancer treatment centres could be specially trained to assist patients, as well as colleagues, to give up this pernicious habit.
Acknowledgements. We wish to acknowledge the continued support of the Cancer Research Campaign and to thank Mrs Eileen Davies for the preparation of the manuscript.
References 1. Rugg T, Saunders MI, Dische S. Smoking and mucosal reactions to radiotherapy. Br J Radiol 1990, 63:554-6. 2. Maciejewski B, Preuss-Bayer G, Trott K-R. The influence of the number of fractions and of the overall treatment time on local control and late complication rate for squamous cell carcinoma of the larynx. Int J Radiat Oncol Biol Phys 1983; 9:321-8. 3. Browman GP, Wong C, Hodson I, et al. Reduced turnout response and survival among patients with head and neck cancer who continue to smoke during radiation therapy. Int J Rad Oncol Biol Phys 1990; 19 Supp 1:143. 4. Saunders MI, Dische S, Grosch EJ, et al. Experience with CHART. Int J Radiat Oncol Biol Phys 1991; 21:871-8. 5. Wells-Jenkins M. Nicotine addiction treated by acupuncture: Acupuncture in medicine. Br Med Acupuncture Soc J 1986; III:l 1. 6. Knudsen N, Schulman S, Fowler R, et al. Why bother with stop-smoking education for lung cancer patients? Oncol Nurs Forum 1984; 11(3):30-3. 7. Royal College of Physicians Report. Health or Smoking. London: Pitman, 1983:126. 8. Eraker SA, Becket MH, Strecher VJ. Smoking behavior, cessation, techniques and the health decision model. Am J Med 1985; 78:817-25. 9. Ferguson P, Small WP. Further study of the smoking habits of hospital nurses. Health Bull 1985; 43:13-8. 10. Laurent C. Resolutions - up in SMOKE. Nuts Mirror 1985; 160:30. 11. Ho AMH. Reducing smoking in hospitals: a time for action. JAMA 1985; 253:299%3000.
Received for publication August 1991 Accepted October 1991