Clinician perspectives on delivering primary and specialty palliative care in community oncology practices.

PURPOSE: Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients' palliative care needs. The aim of this study is to describe community oncology clinicians' primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities. METHODS: Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment. RESULTS: Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%). CONCLUSION: Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients' palliative care needs assessment, documentation, and standardized referral templates.

The natural trajectory of smoking cessation among cancer patients who want to quit "on their own": A mixed-methods, longitudinal study.

INTRODUCTION: Many cancer patients who smoke cigarettes want to quit. Unfortunately, many of these cancer patients prefer to quit without the aid of pharmacotherapy or behavioral counseling. The teachable moment of cancer diagnosis might still position these cancer patients to make meaningful changes in their smoking behavior, but no study has documented the trajectory of smoking cessation outcomes among cancer patients who want to quit "on their own". This study aimed to fill this gap in the literature. METHODS: In this mixed-methods, longitudinal study, 35 cancer patients who declined tobacco treatment because of the desire to quit "on their own" provided data via three surveys and 1-2 semi-structured interviews. The observation period spanned 60 days. Participants were recently diagnosed at and recruited from outpatient cancer clinics. RESULTS: Participants were mostly female (68.57%), White, non-Hispanic (85.71%), unemployed due to disability (57.14%), and rural residents (54.29%). Across time, 43.76% of participants achieved 50% smoking reduction, 21.88% achieved 3-day floating abstinence, 18.75% achieved 7-day floating abstinence, and 12.50% achieved 30-day point prevalence abstinence. Key themes that emerged from the interviews centered on intention and confidence to quit and types of tobacco treatment used/received. CONCLUSIONS: This study with cancer patients who desired to quit smoking without assistance found some evidence of quit success, but success waned as criteria grew more stringent. Results showed participants' initial intention to quit unassisted was quite strong, as few reported tobacco treatment use. Interventions to increase uptake of evidence-based tobacco treatment among cancer patients is sorely needed. IMPLICATIONS: The preference to quit smoking without assistance is common among cancer patients, even given lack of evidence supporting its effectiveness. This study is the first to explore the trajectory of smoking cessation outcomes among cancer patients who desire to quit without assistance. These data can be used to develop interventions to increase uptake of tobacco treatment and increase quit success among cancer patients.

Palliative care use and utilization determinants among patients treated for advanced stage lung cancer care in the community and academic medical setting.

PURPOSE: Despite clinical guidelines, palliative care is underutilized during advanced stage lung cancer treatment. To inform interventions to increase its use, patient-level barriers and facilitators (i.e., determinants) need to be characterized, especially among patients living in rural areas or those receiving treatment outside academic medical centers. METHODS: Between 2020 and 2021, advanced stage lung cancer patients (n = 77; 62% rural; 58% receiving care in the community) completed a one-time survey assessing palliative care use and its determinants. Univariate and bivariate analyses described palliative care use and determinants and compared scores by patient demographic (e.g., rural vs. urban) and treatment setting (e.g., community vs. academic medical center) factors. RESULTS: Roughly half said they had never met with a palliative care doctor (49.4%) or nurse (58.4%) as part of cancer care. Only 18% said they knew what palliative care was and could explain it; 17% thought it was the same as hospice. After palliative care was distinguished from hospice, the most frequently cited reasons patients stated they would not seek palliative care were uncertainty about what it would offer (65%), concerns about insurance coverage (63%), difficulty attending multiple appointments (60%), and lack of discussion with an oncologist (59%). The most common reasons patients stated they would seek palliative care were a desire to control pain (62%), oncologist recommendation (58%), and coping support for family and friends (55%). CONCLUSION: Interventions should address knowledge and misconceptions, assess care needs, and facilitate communication between patients and oncologists about palliative care.

Proposing a Model of Proactive Outreach to Advance Clinical Research and Care Delivery for Patients Who Use Tobacco.

There are evidence-based treatments for tobacco dependence, but inequities exist in the access to and reach of these treatments. Traditional models of tobacco treatment delivery are "reactive" and typically provide treatment only to patients who are highly motivated to quit and seek out tobacco treatment. Newer models involve "proactive" outreach, with benefits that include increasing access to tobacco treatment, prompting quit attempts among patients with low motivation, addressing health disparities, and improving population-level quit rates. However, the definition of "proactive" is not clear, and adoption has been slow. This commentary introduces a comprehensive yet flexible model of proactive outreach and describes how proactive outreach can optimize clinical research and care delivery in these domains: (1) identifying the population, (2) offering treatment, and (3) delivering treatment. Dimensions relevant to each domain are the intensity of proactive outreach (low to high) and the extent to which proactive outreach activities rely on human interaction or are facilitated by information technology (IT). Adoption of the proposed proactive outreach model could improve the precision and rigor with which tobacco cessation research and tobacco treatment programs report data, which could have a positive effect on care delivery and patient outcomes.

The State of the Science on Cancer Diagnosis as a "Teachable Moment" for Smoking Cessation: A Scoping Review.

INTRODUCTION: Theoretically, a cancer diagnosis has the potential to spur health behavior changes in physical activity, diet, substance use, medication adherence, and the like. The Teachable Moment heuristic is a parsimonious, transtheoretical framework for understanding the conditions under which behavior change might occur, with constructs that include affective, cognitive, and social factors. Application of the Teachable Moment to smoking cessation after cancer diagnosis might aid selection of predictors in observational studies and inform how to optimally design interventions to promote quit attempts and sustain abstinence, as many smoking cessation interventions for cancer survivors do not yield positive outcomes. AIMS AND METHODS: This scoping review of 47 studies that span nearly 20 years of literature examines the measurement of the Teachable Moment constructs and what empirical support they have in explaining cancer survivors' smoking behavior. RESULTS: From this review, it appears the construct of affective response is more widely explored than risk perceptions, social role, and self-concept. Strong, negative affective responses (e.g., anxiety, general distress) may be a powerful contributor to continued smoking after a cancer diagnosis. Risk perceptions may also play a role in smoking behavior, such that never and former smokers espouse stronger perceptions of smoking-related risks than current smokers. Finally, due to a paucity of studies, the role of cancer survivors' self-concept (e.g., identity as a "cancer survivor") and changes in their social role (e.g., employee, athlete) are unclear contributors to their smoking behavior. In summary, the Teachable Moment holds promise in its application to smoking cessation after a cancer diagnosis, though more direct research is needed. CONCLUSIONS: This scoping review of the scientific literature is the first formal test of the extent to which cancer diagnosis has been explored as a "teachable moment" for smoking cessation, with results that provide insight into issues of measurement precision and breadth as well as empirical support of the "teachable moment" heuristic.

A Daily Assessment Study of Smoking Cessation After a Head and Neck Cancer Diagnosis.

INTRODUCTION: This intensive longitudinal study describes key events in the process of smoking cessation after a new head and neck cancer (HNC) diagnosis. Prior longitudinal studies show some cancer patients quit, while others continue to smoke, but details about the pattern in which these discrete outcomes arise are scarce. This study is meant to help rectify this gap in the literature. AIMS AND METHODS: Participants were 42 HNC patients who reported current smoking at enrollment. Participants were recruited from an outpatient oncology clinic and completed a baseline questionnaire prior to begin a 30-day daily assessment. RESULTS: Few participants (9.52%) achieved 30-day continuous abstinence from smoking. On average, participants reported 9.64 ± 11.93 total days of abstinence. Nearly, all (94.44%, n = 34) participants made at least one quit attempt, with an average of 16.94 ± 11.30 quit attempt days. Fewer participants were able to achieve a 24-hour quit attempt (52.78%, n = 19), with a corresponding average of 5.50 ± 8.69 24-hour days. The median time to first 24-hour quit attempt was 13 days after enrollment. Based on smoking behavioral patterns, participants were categorized into five groups, the most common being "persistent attempters," which involved unsuccessful quit attempts throughout the study. Only 45% of participants (n = 19) used evidence-based treatment, the most common being cessation medication. CONCLUSIONS: This intensive longitudinal study found that cancer diagnosis can spur a lot of efforts to quit smoking. Unfortunately, this study suggests that many quit attempts are short lived, possibly a result of an absence or insufficient use of evidence-based treatments. IMPLICATIONS: For adults who are current smokers at the time of cancer diagnosis, there is a high likelihood of persistent cigarette smoking and use of other tobacco products in the weeks and months after a cancer diagnosis. Furthermore, this study shows that while a lot of quit attempts may occur, few are successful, which may be partly attributable to the low use of evidence-based tobacco treatment. Future research with cancer patients should aim to identify predictors of quit attempts and abstinence as well as treatment utilization.

A Qualitative Study of Smoking-Related Causal Attributions and Risk Perceptions in Cervical Cancer Survivors.

OBJECTIVE: The prevalence of smoking among cervical cancer survivors typically exceeds what is found among women in the general population and other cancer survivors. Yet, there is a dearth of literature on risk and protective factors related to smoking among cervical cancer survivors, especially when it comes to identification of variables that are amendable to intervention. To help fill this gap in the literature, this qualitative study examines the nature of smoking-related causal attributions and risk perceptions in cervical cancer survivors who smoked at cancer diagnosis. METHODS: Participants are 21 female cervical cancer survivors (M=45.7, SD=8.4 years old), all diagnosed in the past five years. Nearly three-quarters of participants reported smoking in the past month. RESULTS: Smoking was not uniformly recognized as a cause of cervical cancer (whether in general or participants' own cancer); the link between smoking and lung, head-neck, and other cancers was more readily accepted. Despite generally weak endorsements of causal attributions, many participants reported smoking significantly increases risk for poor clinical (e.g., recurrence) and quality of life (e.g., pain) outcomes after cervical cancer diagnosis. CONCLUSIONS: Findings suggest cervical cancer survivors may not fully understand or appreciate the role of smoking in cervical cancer risk whereas their beliefs about the role of smoking in cervical cancer prognosis are more well-formed. This study highlights the potential role of causal attributions and risk perceptions in understanding and addressing the smoking-related experience of cervical cancer survivors.

Understanding cancer patients' desire to quit tobacco without assistance: A mixed-methods study.

While many cancer patients who use tobacco try to quit post-diagnosis, some prefer to quit without using tobacco treatment, despite evidence against unassisted quit attempts. This study aimed to understand the rationale for some cancer patients' desire to quit tobacco without assistance. Thirty-five adult cancer patients who currently used tobacco and declined tobacco treatment because of the desire to quit unassisted provided data via a standardized questionnaire and a semi-structured interview. The sample was predominately White, non-Hispanic (85.71%) and female (68.57%). The most common cancer site was gynecological. Key themes that emerged from the interviews were: self-reliance, willpower, social norms, and negative attitudes toward tobacco treatment. The most frequently endorsed barrier to tobacco treatment was "I know others who have quit without tobacco treatment" (82.86%). This study with cancer patients identified affective, cognitive, and personality factors related to quitting unassisted, and social and systemic reasons to not use tobacco treatment.

Similarities and differences across the underlying dimensions of social functioning in rural and nonrural cancer survivors: A mixed-methods study.

PURPOSE: For cancer survivors, social functioning greatly influences other quality of life dimensions. While there is potential for differences in social functioning to vary as a function of geographic residence, few studies examine the social functioning of rural cancer survivors specifically. This study aims to help fill this gap. METHODS: This was an embedded mixed-methods study where all participants completed a questionnaire, and some were purposively selected to complete an interview to gather more information about social functioning (ie, social roles, activities, network, support, and constraint). Participants (n = 93; 63% rural) were recruited through a state cancer registry and cancer care facility. Participants were predominately White, non-Hispanic (92.47%), roughly half female (54.84%), and on average, diagnosed in the past two years (SD = 1.68), and 61.45 (SD = 10.87) years old. FINDINGS: Few differences in the social functioning of rural and nonrural participants were found on questionnaires, though rural participants reported larger networks and more overall support. Across groups, common themes in the interview data were the experience of both social support (eg, instrumental support) and social constraint (eg, others minimizing participants' problems or sharing their own negative experiences). CONCLUSIONS: This was the first cancer survivorship study to thoroughly examine social functioning by geographic residence. Rural cancer survivors described some unique strengths, but major group differences were not apparent. All participants highlighted situations when others, even with good intentions, were unhelpful to them. Future interventions to improve social functioning could work to dispel the belief that cancer survivors should handle their cancer on their own.

A descriptive study of cervical cancer survivors' persistent smoking behavior and perceived barriers to quitting.

OBJECTIVE: Cervical cancer survivors (CCS) tend to smoke cigarettes at rates much higher than other cancer survivors and women in the general population. However, few studies take a deep dive into the smoking behavior of cervical cancer survivors and none focus on the barriers they experience related to smoking cessation. This study aimed to describe CCS' tobacco use characteristics, quit attempts, and barriers to quit success. METHOD: In a concurrent mixed-method design, 50 CCS (94% White nonHispanic) who were diagnosed in the past 5 years and were current smokers at diagnosis provided data via standardized questionnaire and semi-structured interview. RESULTS: More than three-quarters of participants were current smokers at the time of study participation, 25.6% of whom also reported noncigarette tobacco use (e.g., electronic cigarette, cigar, snus). Seventy percent of participants reported making at least one 24 hr quit attempt postdiagnosis, with 61.5% of current smokers preferring to quit without professional advice or counseling and 51.3% preferring to quit without medication assistance. Four themes emerged regarding barriers to smoking cessation: motivation and readiness; confidence and uncertainty; triggers; and social and environmental factors. CONCLUSIONS: The rate of smoking in CCS is remarkably high, which may partly be explained by negative attitudes toward and low use of evidence-based treatment as well as multi-level barriers to smoking cessation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Tobacco Use and Tobacco Treatment Referral Response of Patients With Cancer: Implementation Outcomes at a National Cancer Institute-Designated Cancer Center.

PURPOSE: Smoking after a cancer diagnosis is linked to cancer-specific and all-cause mortality, among other adverse outcomes. Yet, 10%-20% of US cancer survivors are current smokers. Implementation of evidence-based tobacco treatment in cancer care facilities is widely recommended, yet rarely accomplished. This study focuses on the early outcomes of a population-based tobacco treatment program integrated within an National Cancer Institute-designated cancer center. METHODS AND MATERIALS: The sample consists of 26,365 patients seen at the cancer center during the first 18 months of program implementation. The study is a retrospective chart review of patients' tobacco use and, among current users, patients' treatment referral response. RESULTS: More than 99% of patients were screened for tobacco use. Current (past month) use was observed in 21.05% of patients; cigarettes were the most popular product. Only 17.22% of current users accepted a referral for tobacco treatment; among current users who declined, the majority were not ready to quit (65.84%) or wanted to quit on their own (27.01%). Multiple demographic variables were associated with tobacco use and treatment referral response outcomes. CONCLUSION: Despite cancer diagnosis presenting a teachable moment for tobacco cessation, patients with cancer may not be ready to quit or engage with treatment. Clinically proven strategies to increase motivation, prompt quit attempts, and encourage treatment use should be key components of tobacco treatment delivery to patients with cancer.

A cluster randomized controlled trial for a multi-level, clinic-based smoking cessation program with women in Appalachian communities: study protocol for the "Break Free" program.

BACKGROUND: The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program. METHODS: The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness. DISCUSSION: Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020).