DR. GRAHAM WARREN: Thank you very much for having me. I certainly appreciate the opportunity to come. I've
learned a lot since I've been here, just in a few short days.
I love the cultural differences and especially the wording and some of the
habits I've seen. It's been very, very nice. So thank you for having me. As we... make
sure I've got this right... as we talk a little bit about today, I want to try and
see if I can make you think a little bit differently about a problem that perhaps you
believe that you've thought about quite a bit, but hopefully try and convince you
there may be some additional things to consider. I do have to give you some
disclosures. Long short of it is, there are several committees, grants, things
like that. This is not something that I'm going to try and give you non-evidence-based,
these are evidence-based findings, they are not things that will be made
money on. I don't have anything to disclose or otherwise. To start, we know
that smoking is the largest preventable risk factor to associate with the
development of cancer. Several different cancers, this has been well known. There's
about 7,000 compounds of cigarette smoke, actually there's 65 known carcinogens
and there's a lot of stuff that's been added to try and increase addictions,
specifically to try and increase absorption, addiction, flavoring and so
forth. So you can add a lot of things to tobacco, you light it on fire,
that won't be good. About 10 years ago, sorry, about 15 years ago, I actually
downloaded additives to cigarettes from a website. There's a tobacco website. There's
a lot of interesting things that can be added here. I've highlighted a few
examples in bold: acetic acid, ammonia, apple juice concentrate. And if you
want to know what the entire list of things that could be added, here's the
list of chemicals. And this isn't rocket surgery, you can... if you light all this on
fire and you inhale it, it's going to be bad for you. And so, we've done a lot to
know that smoking increases the risk of developing cancer. You might ask yourself,
why do we do this? Well, this is a map of the United States that shows geographic
distributions that came out from 2012, a behavioral risk factor survey. And I don't have the data actually
for Australia right now, but there's a huge difference on
regional use patterns. This is not something that's one-size-fits-all, there
are cultural differences also in the United States for tobacco patterns. And
perhaps the most common theme is that you have a big distribution of tobacco
use, particularly in the United States, in a certain region: the southeast,
in Appalachian areas. Now, I don't know if I have a pointer here, but the brown
state you see right there in the middle is Kentucky. I always joke around with
people that there's a couple of little white dots here in Kentucky that look
like maybe there's not tobacco. I always joke that that's just an area where they
didn't go in to ask any questions. And this is important because with regards
to rural access and the ability to identify use patterns, risk and outcomes, you're
limited in part by the ability to effectively communicate with people in
different regions. We have the exact same issues throughout the United States.
However, if you wonder why it is that people smoke: if your mom smokes, your dad
smokes, your brother or sister smoke, there's a good chance you're gonna smoke. And
just for disclosure, to let you know this is actually my son. He's now 13. We
penciled the stogie in - the cigar - right there. He still has his little "Mom"
tattoo right there. But it's a hard habit to break and when you look at addressing
tobacco use, particularly in cancer patients, you got to remember the
overwhelming majority of these patients started smoking when they were teenagers -
12, 14 ,16, certainly before 18 years old - almost across the board. This is an
imprinting habit that is exceptionally hard to break and this is something that
even after 20 years of cessation, you can walk through a puff of smoke, you'll feel
the buzz, you'll want to smoke again. So this is a huge imprinting behavior
that's particularly hard to change around the time of certainly getting
cancer. Now you might ask yourself, why do we care about cancer patients anyway
with regards to smoking? We can treat them and do just fine. Well, as David said
earlier, in 2014, the Surgeon General's report was the first one to actually try
and evaluate what were the effects of tobacco use on cancer treatment outcomes
and this was actually about 1800 man hours of work by me for what turned out
to be five pages in this report. So if you get called by the Surgeon General's
committee to write something, you're going to spend more time than you might
originally think. However, this was nice because this really reviewed about
everything between 1990 and 2012. There's about 450 studies that went into
this, and of these studies, we really tried to focus on what were the effects
of tobacco on survival treatment outcomes or
currents and things like that. Now, I spent a lot of time putting this
together but this was really... the data that was put together went through 15
levels of review. I don't know if you've heard of the word "bureaucracy". I think
I've heard of that once or twice here in Australia, but there was a huge
number of people that reviewed the findings so the conclusions technically
wouldn't know what they were going to be until the final report came out. The
conclusions that came out were striking. The evidence was sufficient to
demonstrate that smoking by cancer patients and survivors caused adverse
outcomes. It specifically increased overall
mortality and cancer-related mortality. It increased the risk of getting a
second primary cancer and there were very strong associations between smoking
and cancer treatment toxicity. The magnitude of these effects was
substantial. If you take a look here, this is actually kind of a summary of the
median effects of smoking: positive and negative studies across all cancer
disease sites and treatments. With regards to overall mortality, with current
smoking, you increase the risk across disease sites of treatments by about 51%,
cancer-related mortalities 61%. And you can see former smoking, you know, quitting
smoking in the past, those risks were substantially reduced or non significant
whatsoever. So, current smoking was strongly associated with adverse
outcomes. And you might think to yourself, well, this is a head, neck or a lung
cancer problem. Well, if you go through and you try and actually identify the
studies that have looked across a spectrum of cancers, this actually is a
bar graph to kind of give you an idea based on-- and the red actually
shows - hopefully those of you who are red-green colourblind, the ones on the left -
the red bars indicate the number of studies that showed significant negative
associations between tobacco use and at least one outcome survival toxicity
recurrence, whatever it may be. You can see across head and neck, lung, breast,
prostate, hematologic, GU, GI, this isn't a head, neck and lung cancer problem. This
is a cancer problem. The effects are true across disease sites and treatments and
so you can really use this as a way to try and address a variable that's
important, within reason, pretty much across cancer
as a whole. I like to use prostate cancer as an example. What do most prostate
cancer patients die of? Anyone? I guess I shouldn't wait for an answer. But
not prostate cancer! They die of something other than prostate
cancer and this is actually a nice study to highlight some of the
significance of smoking in prostate cancer patients. You can see here, in
these 1300 patients, about 10% - or actually 8.7% - died
of prostate cancer, 90% have died of something else and you can see the risk
ratios for current smoking on those risks outside of prostate cancer were
enormous. And so smoking, I like to give an example, prostate and breast cancer,
which now also has a very high cure rate, these are patients that may benefit even
more than lung or head/neck cancer patients simply because their survival
and cure rates are so high. This is a... we're doing a lot of work right now to
try and specifically summarize studies that have looked at the effects of
tobacco cessation in cancer patients and we have a number of studies - this will be
coming out shortly - this is a preview of parts of it, but you can see: are there
benefits to cessation? Well, there's a lot of different things that have been looked at:
overall survival, recurrence, quality of life, toxicity, things like that. This is
the summary just for overall mortality. And just as you can see a consistent
pattern of significant reductions in mortality in people who quit smoking. So
there are benefits to cessation. It makes a difference. Now, you might think to
yourself, clinical trials are designed to try and advance knowledge. Priority
objectives of clinical trials are what? Overall mortality, cancer-related
mortality, progression-free survival, toxicity. Those are primary secondary
objectives of virtually all clinical cooperative group trials or clinical
trials in general. We took a look at this a few years ago to try and evaluate
how is tobacco being evaluated in clinical trials? And we showed here that
71% of cooperative group clinical trials, at least in the United States, didn't assess
tobacco whatsoever. This was received with mixed findings.
Some people were excited to show this and some people were pretty not excited
to see this. This means that we're taking our most advanced cancer treatments - the
next generation of what we're going to do to try and improve outcomes and we're
not assessing a known variable that affects overall survival, cancer-related
mort-- survival, toxicity from cancer treatment. And so eliminating this
variable could significantly skew or bias results in clinical trial design.
So then we went back and said, well, what happens with regards to oncologists and
practicing physicians? And we sent out three different surveys - the first two
have been published, the third one hasn't been published yet.
But we actually looked to find out what do oncologists do about tobacco use? And you
can see here that about 90 percent along the top ask about tobacco use and in
there, in the middle, about 80 percent advise patients to quit, but physicians
report less than 40 percent actually helping patients quit. And if you go to
patient surveys, you'll see that it's actually cut in half: about 20 percent
provide cessation support to try and help people quit. So we went back and
said, well, what can we do about this? We looked at the barriers associated with
this. We looked at a whole variety of different barriers and interestingly
enough, these surveys... 90% of respondents said that tobacco-- they thought tobacco
caused our adverse outcomes and that tobacco cessation should be a
standard part of cancer care. So they were motivated physicians but still
demonstrated those practice patterns. Here, we went back and tried to evaluate
specific barriers. This is too small typing, I know there's too many ratios.
It's actually just a copy and paste right out of our paper. You can
actually see the pattern where specifically time, resources and
education were the dominant barriers to providing cessation support. So now we
have a target, things we might be able to do to try and improve assessment or,
excuse me, providing cessation support for cancer patients
So we did! This was a follow-up survey we sent out to NCI-designated
cancer centers, which we presented in an abstract that's not published yet. And
this was a funny slide. If you look at this, we asked oncologists and said, hey listen,
we're gonna give you the option to try and provide cessation support. How do you
want to do this? Who do you want to provide this? And you can see some said primary
care, some said nurse practitioners. I just want you to try and focus on that
really skinny red part. One percent said they wanted to provide cessation support
themselves. Fifty percent said, I really don't care who does it, just not me. If I
try and get my oncologist to provide cessation support, I'm not sure how well
it's going to happen. I'm not saying don't educate or advocate or anything
like that. But what I'm getting at is that it may
be difficult to educate physicians and expecting to provide the cessation
support necessary to get people to quit. We went back and asked them about
education and cessation support. Only 10 percent said they had adequate training
and again this goes back. Look at that green bar, the second one from the top.
Fifty-five percent said we want you to educate someone, just not me. Anybody else in clinic - just
not me - on how to provide cessation support. I call this a disservice in
cancer care. It's a little bit of irony or maybe cynicism in this talk. We're not
satisfied until you're not satisfied. We can't continue to realise these deficits
if the effects of tobacco are so robust and cause so many problems in our
cancer patients. Well, what can we do about this? Well, we went back-- and I'm a
radiation oncologist. I am not a cessation person, I am not an
epidemiologist - although I have some epidemiology. I'm not a behavioral
economist. I am a radiation oncologist with a PhD in toxicology. I'm
an engineer by heart. If we're gonna do something, I want to do it efficiently
and effectively in a manner that actually produces some kind of results.
So, how do we try and address this in a manner that would translate effectively
but efficiently? Well, we designed a program at Roswell
Park - which is where I was before I am now - which was a phone-based cessation
program that used an automated tobacco cessation approach, where all patients
were screened for tobacco use using a structured questionnaire and electronic
medical record-- were automatically referred to a cessation program that
proactively reached out to call patients. And this was the basic algorithm but
basically, if you screen positive, you were automatically referred and then you
went into a follow-up if you didn't screech positive the first time. From
this, 12000 patients in our screening and 2700 patients referred to our cessation
program, we evaluated the effectiveness of contact and intervention. And you can
see here, we had one and-a-half cessation experts to try and provide cessation
support. So every day we went from the top down and we started trying to call
patients and this really divided it into two different groups. One group, we had
1300 patients where we call them at least five times and we were able to
reach 81% - if you can see that circled in blue. Of the people we contacted, only
3% refused cessation support. That means I've got their attention. 3% said I don't
want to participate. It doesn't mean they quit, it
just means now I've got access. I've got their attention. I have the opportunity
to try and intervene. If you look up at the top right, you're gonna see that we also
sent these big, thick "fat cat" mailings. Fat cat is a great term in the United
States. I haven't heard that here. It probably has an interesting
pronunciation here. Big, thick, expensive mailings: tobacco's bad, give us a call, we
want to help you quit. Out of 1381 patients, 16
patients called our program. 16. I don't find that particularly appealing,
so I don't send mailings anymore. And this is bigger-- the biggest reason why.
Now I told you that efficiency was a big deal. Well, we went back and said, we built
the cessation program from scratch. There's 25 people in the room that we
started this process with. A lot of tobacco cessation experts, they wanted 37
questions on a screening questionnaire. I said, "Guys, you're nuts. This is never
gonna work." But it was a team. We tried to roll it out, nursing said, "We won't do
this." I said, "Okay, let's take it back. I didn't think it'd work. Let's take it back."
We modified and got it down to about 20 questions.
Nursing again said, "This is quite a bit to try and ask all the time because we
tried to ask this every day. Every time a person came in for cancer treatment,
there were people that said we need to ask this every time." I said, "We can't do
this as often but let's give it a try." After two weeks, nursing got back again
and said, "We can't do this, change it or it's gone." And so we went to every two
weeks. There's two important findings that came out of this. First, 99% of
patients, we identified with 3 questions. And as a matter of fact, one question in
particular, how long has it been since you've smoked a cigarette - even a single
puff - is probably the highest yield single question you can ask. It
identifies probably 95% of patients. That gives me efficiency. Then we went back
and looked and said how often do we have to ask this question? And in 428 patients,
428 smoking patients referred to our cessation program - if we ask questions no
more frequently than once a month, we delayed cessation referrals in less than
1% of people who needed support. That's efficiency and I know,
unfortunately, we're the only people that have looked at this in cancer but it
shows that it's possible to try and do this and not be obtrusive. Then we went
back and said, well we got a cessation program. This is great and wonderful but does
it make any difference? We went back and looked at our people in our program who
are current smokers to try and find out if we made any kind of difference. In our
lung cancer patients who were smoking, came to our program and quit, we reduced
mortality by 44%. Lung cancer patients quit smoking, 44% reduction in mortality.
There's nothing I can add to lung cancer treatment to reduce mortality by 44
percent, to whatever the front-line treatment is going to be. And this isn't
the definitive answer, this is a strong signal. A phone-based, efficient cessation
program that gets people to quit smoking can manifest in a clinically meaningful
outcome. We showed the same thing for the National Lung Cancer Screening Trial. As
a matter of fact, if people quit smoking for seven years, they equated to the
benefit of CT screening. Anything beyond seven years, their survival was even
better than CT screening. It's amazing how easy it is for a group of
people to work together when they had no idea where they're going. If we've been
trying to figure out how to improve our cancer treatment outcomes and ignore
cessation, we may not be making nearly as much progress as we think we are.
What can we try and do to make this better? Well, we do have guidelines. This
is actually in DeVita. There's a "5 A's," which is a standard approach. It's going
to be in DeVita again, in the upcoming issue. So you have the opportunity to
actually read about cessation if you want to, to some significant degree.
We also... there we go, now have the NCCN Guidelines. And actually I've heard
it, NCCN Guidelines are reasonably-- fairly widely used here. This is great. We, in
2015 NCCN Guidelines advocate for providing cessation support for cancer
patients as a whole and there's guidelines in there to show you how to
do it or to talk about it and I'm gonna get back to this in just a minute,
because remember I showed you that oncologists may not be the optimal group
to provide the cessation support. But the guidelines are here, you have the
evidence base, you can advocate for this. It's bad for treatment and we have
cessation support we need to provide using guidelines. You have an
evidence base to justify development of these programs and approaches. We work at
the NCI and ACR for years to try and develop standardised questions. There was
actually an abstract - I haven't written and I need to actually publish -
because we went back to Surgeon General's report and looked at the
variety of ways that tobacco was defined. There were 75 different ways the current
tobacco use was defined by these studies. It's all over the board and so the
development of standardised structured questions gave us the ability to define
it very well in an efficient manner but also be able to compare it across
different groups, different studies and so forth. The common core questions are
here from the NCI and ACR Task Group and this goes back - if you look there at
the bottom - how long has it been since you smoked a cigarette even a single
puff or one or two puffs? You have an annotated response: less than one day, one
to seven, seven to thirty days. People who used tobacco in the past 30 days need
cessation support and that's in the NCCN guidelines. So as silly as it sounds, over
the past 10 years, we've actually started really gaining consensus across
guidelines, across questions and across clinical effectiveness. Now, this is an
accident study. I started a study in head/neck cancer patients, where we came in
and said, "We want to... we're going to treat you with radiation chemotherapy. We're
going to ask you about tobacco use every week during treatment, we're going to take
blood every week during treatment and we're going to measure tobacco in your
blood. Do you want to participate or not?" And they said yes. We didn't pay them
anything. You would think, the person knew we were going to measure in their blood, they'd
tell us accurately what was happening. But you'll see from this little red line at
the bottom, every week-- week after week, there's a group of people who will not
tell you the truth. I know, it's hard to believe. Every week. And we've seen the
same thing in other disease sites: breast, prostate, lung, and other studies have
shown the same thing. Long and short of it is that there is an opportunity to provide
biochemical confirmation for people who are very interested in this and there's
a value because about 30% of people who have-- 30% of cancer patients who smoke
will misrepresent tobacco use. So that's not something that I'm saying you have
to do, but if you do want to get an accurate assessment, biochemical
confirmation can assist quite a bit. I refinanced our house a few years ago and
I was put on one of these email lists. I don't know exactly but I get these kind
of offers all the time. "I'm Dr. "can't pronounce the name" and I
have a bunch of money, just give me your account and your social security
number, we'll send it to you." It sounds like a great idea but maybe we haven't really
thought about all the aspects of trying to participate in it, right? There's
something you need to think about and unfortunately we haven't done it a good
job of. Biology. The biologic effects of tobacco lead obviously to developing
cancer. If you think that once you get cancer, it turns off the effects of
tobacco, I'm gonna argue that you're probably wrong. But unfortunately we have
not done a good job of identifying the biologic effects of tobacco and how we
might be able to use this to improve our cancer treatment approaches. We reviewed
this a few years ago and found about 34 studies that actually looked at the
effects of tobacco in cancer cells. So we started playing with this for a while.
And this is all unpublished data, we've been developing this model for several
years and actually working on biologic outcomes. So you want to talk about
current, recent data: this is as current as it will get. And the entire audience, I
just want you to focus on those two circles in the middle bottom of the
page. Don't worry about the rest. In biologic systems, smoking - chronic
cigarette smoke exposure - decreases the effectiveness of radiation, chemotherapy,
five different chemotherapeutic agents, eight different cancer cell lines very
consistently. And if you want to know the significance, those two circles at the
bottom are called clonogenic survival or colony survival assays and what it is
is that you grow cells up and then you stain them purple and the purple cells
are the ones that are still left. And you can see there at the bottom, the
radiation is the circle on the top. There's not that many cells left when we
treat them with radiation. But when I add cigarette smoke to radiation, the one
below that is the effect. Can you see a difference? Is this what we're doing if
we're treating people with radiation and they're smoking? Do we leave this behind?
This is the kind of question you need to ask yourself and, remember, do I want to
leave this behind if I'm going to treat someone with radiation and chemotherapy?
These are the types of things that we haven't thought about as well and we
started digging into it further. We actually looked at some of the
reversible effects. We did xenografts, we did tissue specimens. How many people
here are pathologists? Good choice. I guess if I'm being
recorded, I shouldn't say that, right? What we're looking for is black or brown
nuclei here and this is a lung cancer xenograft, which means the lung cancer
took it out. And we looked at something called HIF-1 Alpha and there's a bunch
of things we looked at but HIF-1 Alpha's striking. This shows essentially
no dark nuclei. But what happens if we activate the nicotinic receptor? Can anyone
see a difference here? This is a huge difference, not only that, but look at the
morphologic pattern you have here. The whole tumor doesn't necessarily respond
the same way. You have this characteristic tumor-stromal interface
where you have activation of HIF-1 Alpha in the expression... in the
activation of nicotinic receptors. And then what's really interesting is if you
take it away for three days... look what happens. It goes back. It's reversible. The
biologic effects are reversible. If we're not assessing tobacco in our clinical
trials design, and there's potential interactions between biology and protein
expression, and we're randomising our studies to treatment based on protein
expression, are we missing the boat? Is this something that's going to add
significant bias to it? We already know it makes a difference for outcomes. We
need to start thinking about tobacco - not as just a stigma and a behavioural thing -
but as a biological, behavioral, societal, clinical - and I'm going to offer
one more thing - cost-determined outcome. We looked at this a little further, as a
matter of fact, and we found - this is, you're gonna notice here, this is highly unlabelled - we found
a germline polymorphism that about 50% of the people have and about
50% don't. And if you have this, you drive a dominant tumor pathway in the presence
of cigarette smoke. Not by itself. In the presence of cigarette smoke you drive a
dominant tumor pathway and you can use a targeted therapeutic to prevent the
effects of cigarette smoke, at least in cell cultures. This is highly preliminary.
But how many of you ever have thought about the possibility of using a
targeted therapeutic to improve outcomes in patients who smoke at time of
diagnosis? And if you haven't thought about that, why haven't
you thought about that? If this makes such a big difference, if it decreases
the effectiveness of cancer treatment reasonably ubiquitously, if we figure out
how that works, we may actually make cancer treatment in general better - not
just for smokers. You know what, today... the only thing I'll say here is that we look
back to this polymorphism, and at the bottom, PD-L1 - an immunotherapy - is the
new thing. We're affecting PD-L1 expression based on its polymorphism. Why
are we running expensive trials and looking at extremely significant
outcomes in the absence of cigarette smoke? It doesn't make sense to me, it's
something that needs to change. Hypothetically, this could change how we
look at it. If you have a person who's a current smoker, you want to get them into a
cessation program. These targeted things are not so that they can keep smoking,
this just tries to increase the effectiveness of cancer treatment. But
what if we had biomarkers trying to help guide treatment further, either from
cessation therapies, targeted therapeutics or otherwise? So we've heard
about staging for cancers. This is my thought process, so there's no evidence
base behind this but I'm going to convert tobacco into stage 1, 2, 3 and
4. Stage 1 is clear evidence that there's an effect. Stage 2 is seeing if
we can actually make things better. We've done that, we've got it. The evidence is
there. We're at stage 3 right now. How do we try and implement change so that
we can manifest and increase cessation activities? What are the programs that
deliver this very well? Stage 4 goes back to that biology. What treatments...
what cancer treatments are better in people who smoke at time of diagnosis?
What types of targeted therapies have we not even thought about to possibly
change outcomes? We've run - there's a group of us - again, you're talking about
new evidence. This isn't published yet either. There's a group of us who have
been working on the cost implications of failure first line cancer treatment in
patients who smoke and this basically shows attributable failures per 1000
patients based on, you know, the prevalence of smoking, the baseline
failure rates, risk ratios for the effects of cigarette smoke and the long and
short of it is that in the United States we have 1.6 million cancer patients
diagnosed every year. If we have a baseline failure
of 30% - which is conservative - and we have a smoking risk that's 1.6 or 60% which
came out of the Surgeon General's report - which again is conservative - that's cancer-related
mortality, first line therapy, failure is going to be higher than that.
If that's the case, if you look - and again this is news could be - the cost of
treatment being 10, 50, 100, 250 thousand dollars for the
cost if you fail first line therapy, here you can see those two red numbers at
50 and 100 thousand dollars which is exceptionally justifiable in
the United States, we have 1.7 to 3.4 billion dollars a year in costs associated with treating first-line cancer treatment failure
because of smoking. Now, I was on a
plane - not sleeping as well as I could - but I did spend time trying to figure
out what the implications were here in New South Wales. Using the same modeling,
If you have 10 thousand dollars per treatment failure, it's about 8
million dollars a cost. If it's 50 thousand - which is, I think, probably where
it is, although I couldn't really get that information - you're talking about
40 million dollars or additional costs. These are from conservative
estimates of just first line treatment failure, not including overall mortality
toxicity, hospitalizations and so forth. This is something we're not going to spend
a whole lot of time on, this will be something we can ask about but when you
think about designing cessation approach, you need to be able to sell it well
enough. You need to think about institutional buy-in, you need to think
about the opportunity to get people involved and you got to have
sustainability. And how you're gonna deliver cessation support is very
important. However, overall, it doesn't have to be that hard. And for a large or
small centre, most of the aspects, including a standardized screening,
referral, pharmacotherapy, counselling, referral to a quitline and buy-in can
happen in any place. The real aspects or whether or not you have cessation
specialists or you provide it in the clinic or by phone - these types of things
are a little bit nuanced but really a lot can be consistently thought of and
delivered independent of institution size or clinic size. Right now in the US,
and I think here, we are trying to figure out the diagnostic and treatment
timeline: where you go from an area of concern to
diagnosis to consultation to treatment to follow-up and our goal is to shorten
a time between the area of concern and treatment. And that's what everyone's
trying to focus on. Right now, we have two primary groups that work on this: primary
care works on the early end before diagnosis or before the oncology
consultation - there's a little bit of mix - then you got oncology care, that unfortunately
there's a nice blue arrow to try and get things back to primary care but it
doesn't happen very often. Think about how you can engage tobacco cessation
across this timeline. The reason this is such a big deal is because the longer
you quit smoking, the better your therapeutic response is going to be. If
you can quit for a month, it's going to be better than if you quit for a day. If
you quit for two months, it'll be better than probably a month. If you can take
advantage of this timeline of concern to diagnosis to treatment and provide
cessation support particularly in that timeline in preparation for cancer
treatment, that's our best chance to try and improve clinical outcomes. I'm going
to advocate in my experience to think about an "ask, advise and refer" or "ask,
advise and connect" model, which is - for me - essentially the same thing. Asking: you
identify tobacco use for structured assessments, advising: this is
where clinicians across the entire spectrum of care need to have the same
message. Every clinicians to say, "Hey listen, tobacco's bad and your cancer
treatment, you know, is gonna-- the best chance of you getting a successful
cancer treatment is to try and quit smoking." That's what you can do to try and make
things better. If you don't know how to quit, that's fine. Say, "I have no idea how
you're gonna quit but, you know, we got a cessation program to help you quit or
we're gonna give you access to this. I have no idea how you're gonna quit, we're
gonna use this program." Ask them how they're doing. How you doing with your
your quitting? Or how are you doing with smoking? And if they've reduced, say
great job! Don't criticize them for continuing to smoke. Remember, this is a
systemic addiction that started when they were 14 years old and they got
cancer. It is hard. Congratulate progress, connect
them to a cessation support. Additional considerations to think about, okay? And
this is something that you have to buy into. I know how we are and I'm happy to
help with these types of things. How do you synergise a research message with
clinical delivery? There are huge research questions coupled with
clinical effectiveness with regards to tobacco and cancer patients. Consistent
documentation and assessment, efficiency - try and coordinate across lots of
different centers and then message with a clear vision. "Tobacco's bad, this is
something you can do to try and make your cancer treatment better and we are
in this together." And I like to emphasize that "we're in
this together." Get your clinic to buy in: your receptionist, your technicians, all nurses,
physicians, administrators. Buy in. This needs to be updated but I want you to
realise that when you think about tobacco in cancer patients, you've got
the biologic effects, the clinical effects, tobacco cessation. I used to have
population but really tobacco cessation related things. And then we are being
pushed more and more into the cost variables associated with this. The
facets associated with tobacco use and cancer patients are significant. Don't
just think of it as smoking, they don't care, we're not going to provide cessation
support. Right now, this is possibly one of the best opportunities we have to
improve cancer treatment as a whole. It's difficult to comprehend and how insane
some people can be, especially when you're insane. I agree.
We're not training people as well. We're not thinking about this the same way.
We're not getting our residents or medical students thinking the same way.
We've got to think a little different and I hope you walk out of today
thinking just a little different. Thinking this is something that we need
to do and this something is important. This slide will never go away.
I try to, you know, my favourite thing is that top left: statistics show that teen
pregnancy drops off significantly after age 25. [laughter] Yeah, I agree. I don't even know
anything about that study, that's a 100 percent right, right? Sometimes,
the question in front of us is very, very straightforward and obvious. This is one
of them. Tobacco doesn't stop at a cancer
diagnosis, it continues after. The question is: what can we do to address
this to improve our therapeutic outcomes for cancer patients? And this is my talk
for the day, I think I can take questions, is that right?
Right so thank you for having me.
JULIE McCROSSIN: Ladies and gentlemen. I was so busy tweeting
there was a slight pause. That was an absolutely gripping presentation and we
do have time for questions or comments from the floor so wave at me and I come
to you with surprising speed. And someone called Laura is going to come out the
front and she's getting the app questions and there she is. You wave at
me when you've got an app question. Where was the gentleman who just waved? Thank
you. Do you mind just introducing yourself?
LEN THOMAS: Len Thomas is my name. I work
with holistic health. The problem I find starts within the saliva glands and
we're going to try and get the changes starting from there because it's coming
in to the saliva glands. Also when I'm working with people I can actually tell
whether they were fair dinkum about giving up smoking or not because I can
smell it. And it stinks. On top of that, I gave up smoking 30 years ago - 80 a day.
JULIE McCROSSIN: Excuse me, but at a conference like this there is meant to be spontaneous
applause. [laughter]
LEN THOMAS: Yeah, straight dead cold. Didn't go through any therapies or anything. I
suppose I had it within myself to just give it up.
And never had another smoke since. DR. WARREN: Thank you.
JULIE McCROSSIN: Thank you so much. Could I just
ask you, what do we know about different variable responses to different
strategies? Because we're encouraging people for referral... is it common
for people to be able to stop completely alone, others need support. Do we have any
evidence about that?
DR. WARREN: Oh yes, this is actually-- we've talked about this a
lot the past couple days. We do an exceptionally poor job providing
cessation support for cancer patients as a planet. In general, five or maybe ten
percent of patients who smoke at the time of diagnosis get access to
cessation support and we've got some studies that report on those two or
three or five or eight percent of patients. I don't have the information on the
other 90%. Give me the information on the other 90%. What I mean by that is that in
general, some people will quit on their own. Some people need a little bit of
support and they'll quit. Some people need a lot of support to quit and some
people won't quit and you can't do anything by me, they're just gonna keep
going. And we've seen this in clinical practice. These are not, you know, rocket
surgery ideas. This, we see. The access to cessation support needs to be provided
for everyone. From this, we will start to learn what groups of patients really
respond well to minimal intervention, what or who responds very well to phone-based
support or maybe an app or intensive support really in a clinic without
chemical confirmations. We don't have good distributions on the overwhelming
majority of patients who smoke at the time of diagnosis so there is a graded
response. We've seen that a lot ourselves. We have a fairly, you know, universal
automated program we have quite a bit experience with. What we need to do is
get everyone involved and start to tease out what those greater responses are,
based on what the intervention, you know, the optimal intervention would be.
JULIE McCROSSIN: Thank you, another question, thanks. And if people could just introduce
themselves and I'll hold the mic.
PHILIP BEALE: Philip Beale, I'm the Director of Cancer Services
at Sydney Local Health District. I'd be interested, in terms of what has
happened in the US in terms of with this data coming out over the-- over time
and what has been the the way that clinical, you know, cancer centers have
approached this versus maybe the other models whereby people are seen in the
offices of the oncologists, for example, and how they've sort of banded
together to work out a pathway for that service and have you seen that happening
actively?
DR. WARREN: So we-- I actually tried to help a lot of places start programs and
some were successful and some of them have not. I would say that buy-in at the
highest level is very important, particularly in the United States. If the
person who writes the checks buys into it, you're gonna have a sustainable approach.
Having said that, this is kind of strange. You know, I realised this a couple years
ago. In the past ten years, we've changed the approach to looking at tobacco and
cancer patients really as a whole. We have a Surgeon General's report, we have opt-
out-type programs we've developed that improve
survival, we started some statewide initiatives, we've got NCI that really
bought into this - they've started a new funding mechanism for this,
we got the NCCN guidelines that are dealing with this now and what I'm getting
at is that we've changed the perception of practice. Now a lot of places are
starting to try and develop them. Rarely do you actually see the translation of
something into practice in 1) in a career and in 2) over a relatively
short period of time of ten years. The individualised practice is exceptionally
important. I don't have two places that do the same thing and it's because
nursing, intakes, scheduling, billing, equity with regards to philanthropic or
charitable types of donations could or could not be important. The specifics of
how patients come through a clinic and the resources available is absolutely
critical to consider in how you develop and maintain a cessation approach. In
reality right now, the most important thing is to get everyone in. Once we get
everyone in, get some researchers who know what they're doing to look at the
data and find out what groups of patients respond really well and
where are the gaps? That'll come a couple years after you
get everyone in - and we're doing that ourselves - but the goal will be to try
and start providing evidence-based care across the spectrum and it will vary by institution.
JULIE McCROSSIN: I'll hold it. Can you just introduce yourself? I hold it, yes.
DAVID SINNETH: Okay. My name is David Sinneth and in this environment, I'm a layman, I'm a consumer
representative and I have a question rather than a comment, please. In any
cessation program, have you included a sports medic, a physiotherapist,
anybody who could talk to - this goes right back to primary health care -
someone who can say your physical performance will improve if you give up
smoking so whatever that person's ambitions are - particularly if they play
a sport, active - right back to primary health care, do you actually address
how giving up smoking will improve their physical performance? DR. WARREN: We do. So, two,
I want to make sure I understand it right. So did we involve someone for
performance in the start? We involve patients in the development of these
initiatives, but they were cancer patients, not necessarily athletes or
performance. However the performance has been addressed a lot of times in the
past, we used that data from the past. So improved breathing, improved heart rate,
reduced blood pressure, increased oxygenation, more energy. Those types of
things we do use in our cessation discussions and so yes, we do that.
Secondarily, we didn't approach a patient-- we didn't approach anyone for the
development of our cessation programs related to the performance we did with
regards to cancer care and so hopefully that-- does that answer your question well
enough? JULIE McCROSSIN: Can I just ask you-- oh I'll come back to this gentleman, I'll come back
here in a second. Because I had a follow-up to--
DAVID SINNETH: Oh, the only question is, did it work?
DR. WARREN: It really motivates some people, some people it
doesn't motivate as much. I think it goes back to a little bit of an individual. I
hate to say it but I don't smoke but I got some other things I got to work on
that are not great health conditions, right? So, you know, some people's
receptiveness differs. And I'll use this as example, a lot of times
people ask me about metastatic cancer patients. Should we get people who
we're not going to cure cancer to quit smoking? I use this as an example because we
know that smoking will decrease the chance of hospitalisation of toxicity. If
you let a physician decide, "Hey they got metastatic cancer, I'm not gonna provide
cessation support," I disagree. Let the patient decide. Say, "Listen, you know what,
I don't know if I'm gonna cure your cancer but if I keep you out of the
hospital, is that worthwhile?" And it goes back to kind of a performance and
letting someone decide, do I want to try and have the opportunity to go to the
hospital less often by quitting smoking? And so it is designed around trying to
identify, I would say, performance-related variables in the context of cancer but
we also use the known literature associated with, you know, energy, health,
oxygenation, things like that. JULIE McCROSSIN: And Dr. Warren, I was just going to
bounce out of that gentleman into the primary health world, the world of
general practice because, as a cancer patient,
I know you've had a big focus on that intervention during the acute treatment
phase but there's that terrible moment when your period of treatment is over and you
let-- you get away from the mothership of the hospital and you're hurled back to
the general practitioner in our system and then you have several years of
follow-up which I'm still in. So really, general practice has to be hand in glove
with this strategy, both having the same message but also supporting the ongoing
reduction or cessation of smoking. So where does what we call general practice
fit in? DR. WARREN: So I'm going to ask one quick question and answer that.
How many people here are general practitioners?
JULIE McCROSSIN: That's a spooky result.
DR. WARREN: That's the problem we have in
the United States. We have oncology conferences and we don't have general
practitioners involved. This is an excellent, outstanding opportunity to
engage across cancer care in general practice. General practitioners know how
to do cessation for-- I don't know how many people in here know how to do it, I
can tell you they know really how to do it.
They probably have been trying to make it happen for years and this is an opportunity to
connect between these two exceptionally well. And that's one of the things when
you do oncology - and we're trying to do in the US now - is to reach out to primary
care. And simple messaging, the message for primary care for this is: if you
think you have a patient with cancer, start the discussion on cessation
because it makes a huge difference for the outcome. That's it. After that they
can do the rest of the cessation or what they've been trying to do. Changing the
messaging with a clear vision might be a huge, you know, boost to trying to make
even these better outcomes realised. JULIE McCROSSIN: Anyone here from a primary health
network? Thank God. So just to help Dr. Warren, well, no I won't talk. I'm going to
come back to that poor young man who's still standing up but standing is a form
of exercise and incidental exercise helps to keep us alive. Put your hand up if
you're from a PHN so I run to you. Do you want to just quickly stand up and just
explain to Dr. Warren what a primary health network is? Won't this be an
interesting answer? It's got to be quick, I'll hold the mic. AUDIENCE MEMBER: Oh sure.
Primary health networks in Australia support the work of general practices
and primary care services, so to strengthen support and advocate for
primary care services and often the interface with tertiary care services as
well. JULIE McCROSSIN: And so is smoking cessation a main theme in the world of primary health
networks? AUDIENCE MEMBER: I think it may be variable. I know our PHN has just commenced a
project grant with-- in partnership with the Cancer Institute around smoking
cessation in pregnant women so some definitely do. JULIE McCROSSIN: Thank you very
much and Dr. Warren, PHNs have buckets of money and they form
partnerships with people meant to be targeting health issues within their
area and every bit of Australia is in a different PHN, so important
partners. Do you want to introduce yourself?
PAUL GROGAN: Hello. Thanks, Graham. JULIE McCROSSIN: Don't worry, I'm going to put it close.
Dr. WARREN: I was told not to be scared of that, by the way, so...
JULIE McCROSSIN: It's for volume purposes and it's a
lot less painful than a cannula. [laughter]
PAUL GROGAN: Great presentation, thank you. Paul Grogan from
Cancer Council Australia. Just a question on given the... given the effects of
nicotine in compromising cancer therapies, are you cautious about
encouraging patients to switch to electronic cigarettes as a strategy?
DR. WARREN: So in this case, we have-- I have to tell you two different things. So I'm the chair or
some role on some organisations so I'm gonna give you two answers. One is the
organisation role and then my response. The organization role - really by and
large, we don't have the data, we cannot recommend e-cigarettes for cessation
and technically we can't recommend them for any changes in, you know, whether they're
better or worse than smoking in cancer patients. Technically, that's really the
position that we're limited to. I know the UK has different positions so that's
that's the the official type of organisation opinion. Now, I'm a radiation
oncologist and next week I'm going to be seeing patients who - maybe not next week
because most of my clinics have been slowed down by this stupid hurricane - but
soon I'm going to see patients again with the same-- that issue. And here's what I
can tell you. 1) I will give nicotine replacement
until the cows come home which means forever in the US. I will give nicotine
replacement to every single patient who smokes and sleep well at night and I'm
happy. I don't have any problems with nicotine because there's no data that
shows that nicotine replacement is bad for cancer patients or treatment outcome.
But I know, without a doubt, smoking is. Period. The second part with regards to
e-cigarettes, the effects-- there's really almost nothing else that I'm aware of
that causes as ubiquitous effect on overall mortality, cancer-related
mortality, toxicity as smoking does. It's hard for me to believe. I mean, anything
else. I don't know if nutrition does that. I-- it's hard for me to imagine that
e-cigarettes would be worse than that. Now we don't know. It'll take five
or ten years for data. When I talk to patients I say, "I don't want you to smoke.
I really don't care what you do, just don't smoke. I want you to try and use
nicotine replacement therapies or Bupropion or Chantix. I'm okay with
talking about those things. But use approved medications, this gets you to
start that. If you can't, you don't, you don't want to, you're using e-cigarettes
and they think that-- you think you're helping-- that they're helping you not smoke,
just don't smoke." I don't say, "Hey, that's going to continue to work." I say, "Listen, let's
just continue to make sure you don't smoke. If you think that's helping, that's
fine, just don't smoke." And I know it sounds a little weird, we got to bridge.
Because right now, I can't-- if I wait five or ten years for the evidence to come
out for e-cigarettes, how many of my patients am I going to kill? How many are
going to recur, die, have toxicity because they don't have any guides behind it, right? So
I am wagering a little bit that e-cigarettes will not be as bad as
smoking. It'll take a while to get that data back. In the meantime, I know smoking
is bad and I want to prevent that as best I can.
Does that help? It's a very tricky type of conversation but a lot of times I get
asked that question.
PAUL GROGAN: Ongoing discussion but that's an interesting perspective, thanks.
JULIE McCROSSIN: Yeah, thank you very much. Now, Laura, run over here as quickly as you
can. Run to me, run to me. You're young. Is there anyone over here with a question
or comment?
DR. WARREN: I do have one comment, probably one for the
crowd. We got to finances and money. Back to this money question, we talk about
paying and supporting and grants and these types of things. For the insurers in the
United States, my question is this? Why do you want to pay that much money for
second line cancer treatment? Would you rather do cessation instead? You're going to
save money if you do that, why do you want to pay for this extra treatment if
you might be able do something to get around it? And so what I'm getting at, is
the traditional mechanisms are trying to provide cessation support, usually
through grant funding or through philanthropy or so forth.
The people who pay for cancer treatment are going to be the ones who financially
benefit the most because they're not going to have to pay for second, third,
fourth, fifth line treatment so I just want to make sure we're kind of on the
same page with that. In very practical terms, the cost savings - you'll have some
with patients, the clinical benefits are going to certainly be there for patients,
the money is going to benefit the people who pay for the cancer care. JULIE McCROSSIN: Okay, thank
you, we're going to an app question.
LAURA: I have lots of questions, thanks everyone.
Dr. Warren, have you studied cultural barriers to accessing cessation programs
and, if yes, what strategies have been put in place to engage those of culturally
and linguistically diverse backgrounds? DR. WARREN: You know, one of my biggest strengths is
the ability to say I don't know? Now I have a little bit of knowledge of this
but a lot of that, I don't know. And what I mean by that is, I'm fairly ubiquitous
in how I talk to people about smoking but also cancer care and I learned an
important lesson a couple years ago from a close colleague of mine that showed
that, in African Americans or black people in the United States, that it
wasn't my communication or physician communication but if they had someone
who was an African American - an elderly African American woman - say the exact
same thing the same way, that the participation was much higher. It
completely opened my eyes to the fact that it didn't-- wasn't my deficit. It was
really - or anything I was doing right or wrong - it was ignorance on my part about
the cultural issues associated with, in this case it was clinical trial design,
but it's the same thing for cancer treatment and the same type of thing
probably for cessation. I don't have the knowledge for what the
cultural influences would be here. I anticipate there are people, maybe in the crowd--
JULIE McCROSSIN: That's what I was just going to say. If there's someone who feels they can offer
a comment in relation to that question because you're... you have some expertise
in relation to multicultural people and cessation programs. Anyone like to
volunteer? It'd be spooky if no one did! But no more spookier than no GPs. Of
course they are hard-working, self-employed people with staff and it's
usually best to get them at night, which I'm sure all the PHN staff know. Thank you.
I'll hold the mic. Do you want to introduce yourself? AUDIENCE MEMBER: I'm from Hunter
New England Health, I'm Aboriginal.
JULIE McCROSSIN: Can you boost my level, please? It has to be
for them to hear. Just trust me, okay. DR. WARREN: It's fun watching this, by the way, when she
does this. It's cracking me up. JULIE McCROSSIN: I know it's funny, really, there are many
conferences where people can't hear each other. If you speak up, I can pull it back.
It's about hearing. AUDIENCE MEMBER: We do a lot of research around how we can deliver
smoking cessation in our mob and what it is, it has to be appropriate
engagement and has to have been led by our people, because we don't trust. So it
can't be people from the cancer centres, it can't be our GPs, it has to have the
appropriate teams behind and it has to come from our elders. Our elders are very
passionate, so that's how we can close the gap in that, in our mobs.
JULIE McCROSSIN: And you're developing lots of Aboriginal materials, specific materials.
Can you just tell us a bit about that? AUDIENCE MEMBER: Oh yes. I've done the-- three years ago, I did a
massive project around the cancer resources for the whole of the district and at
the moment I'm working on going around the whole of the district. We've got the
third largest district - health district - in Australia. JULIE McCROSSIN: Which one's that? AUDIENCE MEMBER: Hunter New
England Health. So it's the size of England, so my role is to develop
resources for a whole lot of districts so I'm going round about eight different
communities having yarn ups around cancer. So we call it Women's Business
Amends Business so we're doing a holistic approach, just not around lines.
So we break out, we have breakout sessions and we're delivering that by
Aboriginal people. I'm on one of the facilitators and then we break out into
the afternoon, we do one palliative, well, we've got no uptake in palliative - all
very limited, so now we call it Finishing Up Business and we're
hoping to develop resources that we can close that gap as well. JULIE McCROSSIN: What have you
learned listening to Dr. Warren? What's he got you thinking about?
AUDIENCE MEMBER: A lot. The cost. The cost and the "survivalship" because most of our people
turn up when they're end-stage because we're frightened because we call
it a white man's disease. So that's where we're trying to break the gap and
understandings. We're actually educating all our-- I think it's about 50
Aboriginal health workers with key messages around early detection and
screening so hopefully we'll close that gap, ensure that all our people get
screened, you know, regularly and don't be ashamed.
What we're saying is, "Don't be shame, be game."
JULIE McCROSSIN: And just one last question. I have
a bit of land out at Wellington, which is about five hours west, and
whenever the local Aboriginal community is having any sort of event, there appears to
be Quit Smoking people there in shirts. Indigenous shirts about Quit Smoking so
what's going on? AUDIENCE MEMBER: A lot. we know-- we know that 40% of our mob smoke but some
communities it's 80% and 45% of our women that are
pregnant are smoking, so that's one of our core focus in our business
plans and our health plans so there's a lot and it's, you know, we've got to
ensure that it's led by the Aboriginal people with our artwork that's
appropriate, and when I say appropriate artwork, it's artwork that's been designed
by the community so it's got to be localized so we can relate to it and
it's all around safety. JULIE McCROSSIN: Thank you very much.
I gave a lot - yes thank you - I gave a lot of extra time, Dr. Warren, because you
can hear in those, you know, tragic figures about proportion of the
population smoking. This is one of the most important groups. Is there any
other human, before I go to the app, who'd like to ask a quick question or a comment?
Please take-- thank you so much, sir and we'll come to more app questions in the
panel, which we'll go to after this question. ALBERT: Hello, my name is
Albert and I work in Prince of Wales. I'm a registered nurse. I used to smoke since
I was 14, exactly as you were saying, Dr. Warren. Enjoyed your presentation, it was
awesome. My question is, why are we not trying to make it harder to purchase
cigarettes in America, in Australia and in any country for that matter, it is
just a matter of walking down the road and you can go and buy them. There should be
some restrictions made because it's a struggle every day to stay away from
cigarettes even though I've given up for like 2 years, it's the hardest thing--
JULIE McCROSSIN: Always a clap when someone talks about giving up. Could I just say you
probably know, sir, that we've got hideous pictures on our cigarettes now and also
there at point of sale, correct me if I get this wrong, guys, they're behind the
kind of whited out cupboards. So they are some initiatives but what would you like
to see? What would be better? ALBERT: I think, I think... look, I see it as a drug - it is a
drug and I think that you shouldn't be able just to walk today to any
supermarket, any store to purchase them and I think there should be some control and,
you know, and this way at least we could try and get as many people off their
habit as possible, if we could make it harder for people to buy. DR. WARREN: And so the--
if-- I will summarise the reason why in one word: it's money. And so the money
that's generated by it still dictates, unfortunately, the distribution, sales, all
these types of things. I will say that, and this will probably increasingly come
forth, there are some reasonably good changes in developed countries with
regards to tobacco use patents that will probably start coming out shortly.
And we're starting to see some shifts and we go to this e-cigarette question:
Tobacco companies are seeing this as well and so their vision is to
transition to things that are not cigarettes - to other products. I am
exceptionally cautious about this. In 1900, we had almost no lung cancer cases
at all. People had to roll their own cigarettes, we had to do some work,
it wasn't engineered to be nearly as addictive, didn't deliver chemicals to
the brain nearly as fast, was harsh to try and smoke, you couldn't inhale as
deeply and over the course of the past hundred years with rolled cigarettes and
mass production and menthol and aeration and pH and all these types of things, the
addictiveness is outstanding. I don't want tobacco as an addictive
consumptive device but I would love to have something like a cigarette to
deliver cancer treatment. I mean, it'd probably be huge and effective and wonderful but
you can't do this with an addictive substance like tobacco, in my opinion.
It'll shift. I don't know how long it will take and unfortunately the money is
the motivation behind it, which drives politics, legislation, international
tobacco control-- and I will also say that that I know parts of this but there are
people who know far, far more - have their entire careers devoted to that
question, the reason why the policies that help limit tobacco use and those
types of things. JULIE McCROSSIN: I'm going to take one more app question and
to encourage app engagement because remember there's a prize. LAURA: All right, how
can we overcome this notion that smoking cessation interventions are someone
else's job? DR. WARREN: So, I'm a radiation oncologist and what I do for patients is I try and
treat with radiation to help something better, help them live longer, decrease
the chance of tumor coming back, help them feel better, maybe you don't have
pain, maybe open an airway, stop bleeding, I don't know, different types of things and
what it comes down to is that in my career I'm going to see maybe 5,000 patients
and in reality, I'm probably really going to benefit about 2,500 - somewhere between two and
three thousand - if I'm pretty effective. With radiation oncologists,
there's a concept and actually medical oncology, surgery so forth. I didn't
ask how many people here were physician, you don't have to raise your hand.
JULIE McCROSSIN: Oh, let's do it. Hand up if you're a doctor. Just to get a sense. Thank you. So, some.
DR. WARREN: So this actually may be good. There's something called
"number needed to treat." How many people do you have to treat to improve one?
In the '90s, there was chemotherapy for breast cancer - CMF - this old chemotherapy.
Been around a long time, was effective, it did a good job. But AC chemotherapy,
which is part of what we do now, it switched-- our entire paradigm shifted to
using chemotherapy of a different type, really because there is about a three to
four percent improvement in overall survival at eight years. If we focused on
four percent, what that means is that the shifting of our care from CMF to AC, the
one chemotherapy to another, was because if we treated 25 patients, we
were going to make one more better. That's number needed to treat. We shifted
our entire care paradigm based on: we treat 25 patients and we improve one.
Smoking, when you look... we're not done with this yet, okay? But I can tell you
the range, when you look at the number needed to treat, the lower the number the
better. For radiation oncologists, in general, a good rule of thumb is that you
need a number needed to treat of about ten. Might be fifteen but in reality, if
you're not going to get a ten percent benefit, it's hard to justify the toxicity.
For smoking, for survival recurrence toxicity, your number needed to treat is
between probably three and five. It's probably no higher than five, might be a
little lower than three, but you're living at three to five. This is the
implications. Let's just go with five. If you have five people that smoke that you
didn't get them to quit, you just caused one of those five to die, recur or have
toxicity. It's your decision. That's what you're going to see when you don't get
someone to quit. The number needed to treat for smoking is astounding and in
this case, I told you earlier, I give nicotine replacement until the cows come home.
I can do other things and sleep well at night. I can't sleep well at night
knowing that every five people that smoke, I just left them alone and didn't do
anything because I know we have the evidence, we have the data. Without a doubt,
die, recur, toxicity at about every three to five patients - you don't get them to
quit, that's what's going to happen to one of them. So the impetus, the
motivation for trying to exert this change - decide for yourselves. Is that
what you want to hang-- you hang your head on when you go home at night? These
are the actual... we talk about cost, we talk about phone
or in person or nicotine or e-cigarettes, all these other things, I think this comes down to
number needed to treat. Decide if that's what you want to think about when you go
to bed at night. Did I miss and cause one of those five people to die, recur or
have toxicity? That's the reality of where we live with it. JULIE McCROSSIN: Ladies and
gentlemen, would you give Dr. Warren a warm round of applause?
For more infomation >> LORAC The Royal Treatment DualEnded Primer Mascara - Duration: 10:39. 
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