Acta Oncologica, 2015; 54: 685–692

ORIGINAL ARTICLE

Predictors of continuous tobacco smoking in a clinical cohort study of Danish laryngeal cancer patients smoking before treated with radiotherapy

PIA KRAUSE MØLLER1, JANNE S. TOLSTRUP2, MAJA H. OLSEN3, SUSANNE O. DALTON3, JENS OVERGAARD4 & JØRGEN JOHANSEN1 1Department

of Oncology, University Hospital, Odense, Denmark, 2National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark, 3Survivorship, Danish Cancer Society Research Center, Copenhagen, Denmark and 4Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark

ABSTRACT Background. Many cancer patients who are smokers when starting cancer therapy continue smoking despite evidence of tobacco smoking as a risk factor for poor treatment response and secondary primary cancers. Small samples and inconsistent results in previous studies warrant further research to identify predictors of being a continuous smoker during and after radiotherapy. Material and methods. In the clinical database of the Danish Head and Neck Cancer Group (DAHANCA), we identified 1455 patients diagnosed with laryngeal cancer between 2000 and 2010, who were all smokers at date of diagnosis and treated with primary radiotherapy. Information on the socio-economic characteristics of the study cohort was obtained from Statistics Denmark the year prior to diagnosis. Logistic regression analyses were applied. Results. In the cohort of laryngeal cancer patients smoking before starting radiotherapy, 50% still smoked one year after radiotherapy similar to the percentage of smokers during treatment. Being younger than 60 years (OR 1.39, 95% CI 1.00–1.91), commenced smoking before the age of 15 (OR 1.77, 95% CI 1.32–2.38), having a poor WHO Performance status (OR 3.09, 95% CI 1.71–5.61), low income (OR 2.21, 95% CI 1.23–3.98) and living alone (OR 1.56, 95% CI 1.13–2.14) were associated with increased risk of continuous smoking during treatment. Similar findings were found two months and one year after radiotherapy, however, no association with living alone (OR 1.08, 95% CI 0.73–1.59) at the one-year follow-up. Tumor stage and the average number of cigarettes smoked per day before radiotherapy were not associated with being a continuous smoker. Conclusion. Younger patients, who had an early smoking initiation, a poor performance status, low income and lived alone, were most likely to continue smoking. Continuous smoking was not related to the extent of disease. The prevalence of continuous smoking after a cancer diagnosis is high and smoking cessation among cancer patients is a topic of growing relevance because of increasing evidence of smoking as a risk factor for adverse health outcomes [1,2]. In a meta-analysis on smoking cessation among head and neck cancer patients approximately one third of smokers at baseline were estimated to continue tobacco use after their diagnosis [3]. Laryngeal cancer is mainly caused by the carcinogenic effect of smoking with a worldwide incidence in 2012 of 156 877 cases, estimated to increase to

270 000 new cases a year in 2035 caused by the demographic effect alone [4]. In Denmark, laryngeal cancer is primarily treated with radiotherapy [5] and continuous smoking during radiotherapy has been associated with compromising the treatment response [6–8] and increasing the treatment-related toxicity and need of hospitalization [9–11]. The treatmentrelated morbidity associated with tobacco smoking is for cancer survivors almost comparable to having other chronic diseases [12,13]. In addition, 23% of laryngeal cancer patients have a new primary cancer within 10 years from radiotherapy and the risk

ECRS manuscript, from the European Cancer Rehabilitation & Survivorship Symposium (ECRS 2014) in Copenhagen in September 2014. Correspondence: P. K. Møller, Odense University Hospital, Department of Oncology, Sdr. Boulevard 29, 5000 Odense C, Denmark. E-mail: Pia.Krause. [email protected] (Received 16 September 2014 ; accepted 3 December 2014 ) ISSN 0284-186X print/ISSN 1651-226X online © 2015 Informa Healthcare DOI: 10.3109/0284186X.2014.996665

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increases with continuous smoking behavior [14]. As a result, implementing smoking cessation programs are recommended to reduce the adverse affects on treatment and survival, and minimize the physical and mental sequelae of cancer [8,11]. Previous studies have investigated potential predictors of continuous smoking behavior after a head and neck cancer diagnosis to identify patients in whom the support of a smoking cessation intervention may be of significant importance [15–17]. However, the ability of these studies to adequately define potential predictor variables of head and neck cancer patients who continue smoking, have been deprived by small, non-homogenous sample sizes and resulted in inconsistent findings. In addition, the predictors of continued smoking among head and neck cancer patients have not been analyzed in a Danish healthcare setting. In this study, the objective was to identify predictors of a continuous smoking behavior among laryngeal cancer patients during the course of radiotherapy, two months after, and one year after completion of radiotherapy. Material and methods This clinical patient cohort was based on data on laryngeal cancer patients from the national clinical database of the Danish Head and Neck Cancer Group (DAHANCA). DAHANCA contains detailed information on TNM classification, symptoms, etiological factors, primary treatment, follow-up status, recurrence, death and cause of death on all cases of head and neck cancer (HNC) since 1991 (laryngeal carcinoma since 1971). Head and neck cancer patients in Denmark are mainly treated with primary curative radiotherapy (RT) (66–68 Gy in 33–34 fractions, 5–6 fractions per week) with a five-year follow-up scheduled every third month two years following treatment [5]. All Danish men and women diagnosed and registered with laryngeal cancer between 2000 and 2010 (n ⫽ 2485) were extracted from DAHANCA (Figure 1). Of all Danish laryngeal cancer patients registered with a smoking status (n ⫽ 2396) 70% were current smokers, defined as patients smoking at time of diagnosis or having reported smoking cessation equal to the year of diagnosis. Time of diagnosis (baseline) is the first consult at the Department of Oncology, where the patient is diagnosed, and together with the oncologist decide for the primary treatment of radiotherapy. Patients with no smoking status at baseline (n ⫽ 89) or year of diagnosis/ radiotherapy registered (n ⫽ 4) were excluded together with patients receiving no radiotherapy or only palliative radiotherapy (total dose ⬍ 52 Gy) (n ⫽ 330). Finally, patients registered as never-smokers (4%) or

Figure 1. Flowchart.

ex-smokers (26%) (n ⫽ 607) were excluded, leaving a sample size of 1455 patients receiving primary radiotherapy for laryngeal carcinoma and smoking, when diagnosed (baseline) (Figure 1). The patient data extracted from DAHANCA was based on three standard forms filled out by physicians at the five oncology centers treating Danish head and neck cancer patients. The baseline data was registered at time of diagnosis and a clinical assessment and registration of tobacco smoking were gathered at weekly follow-ups during the course of radiotherapy and at follow-up two months and one year after treatment [5]. Data on age and age started smoking were dichotomized into age-groups (age ⬍ 60 years⬎) (age started smoking ⬍ 15 years⬎). The daily average tobacco consumption was recalculated into number of cigarettes per day (1 g of tobacco per cigarette) and divided into three groups [light smokers (⬍ 10 cigarettes/day), moderate smokers (10–20 cigarettes/ day) and heavy smokers (⬎ 20 cigarettes/day)]. The 10-year period where the patients were diagnosed was divided into three periods of diagnosis (2000– 2003, 2004–2007 and 2008–2010). The WHO performance status classification was used as a surrogate for the general health of the patient at time of diagnosis, thus performance status 4 and 5 were excluded (only two cases) (Table I).

Predictors of continuous tobacco smoking Register data All Danish residents are assigned a 10-digit civil registration (CPR) number either at birth or immigration, which enables linking information from all Danish registers [18]. Information on individual

Table I. Descriptive characteristics (1455 Danish laryngeal cancer patients, 2000–2010). Characteristics Demographic factors Gender (n ⫽ 1455) Men Women Age, years (n ⫽ 1455) Median age, years (range 28–91) ⬍ 60 years ⱖ 60 years Tobacco factors Number of cigarettes/day (n ⫽ 1357) Light smoker (⬍ 10) Moderate smoker (10–20) Heavy smoker (⬎ 20) Age started smoking (n ⫽ 1288) Median age, years Age 0–15 Age ⬎ 15 Socio-economic factors Highest attained education (n ⫽ 1377) Basic school, 7–12 years Vocational training, 10–12 years Higher education, ⬎ 13 years Cohabitation status (n ⫽ 1442) Living alone Cohabiting Disposable income quintiles (n ⫽ 1444) 1 (lowest) 2 3 4 5 (highest) Clinical factors Period of diagnosis (n ⫽ 1455) 2000–2003 2004–2007 2008–2010 Performance status (n ⫽ 1293) 0 1 2–3 Number of symptoms (n ⫽ 1418) 1 2 3 Tumor classification (n ⫽ 1440) T1–T2 T3–T4 Lymph node status (n ⫽ 1449) N0 N1–N3 Stage (n ⫽ 1408) I–II III–IV

N

%

1190 265

82 18

63 554 901

38 62

188 340 829

14 25 61

15 744 544

58 42

487 733 157

35 53 12

630 812

44 56

376 465 251 183 169

26 32 17 13 12

538 554 361

37 38 25

751 413 129

58 32 10

883 334 201

62 24 14

1070 370

74 26

1060 389

73 27

836 572

59 41

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socio-economic position was obtained from the population-based Integrated Database for Labour Market Research established in 1980 by Statistics Denmark containing annual data on a broad range of socio-demographic factors. Highest attained educational level was obtained by 1 October the year before diagnosis and categorized in basic school, vocational training and higher education. Information on cohabitation status (living alone or cohabiting) was obtained by 1 January the year of diagnosis. Finally, the patient’s disposable income was obtained in the year before diagnosis and grouped into quintiles based on the entire population of the same age group, calculated per household after taxation and interest per person, adjusted for number of persons in the household and deflated according to the 2000 value of the Danish Crown (DKK) [19] (Table I). Follow-up Smoking status was obtained from diagnosis (baseline) to the one-year follow-up (Figure 2). The endpoints were smoking: 1) during the weeks of radiotherapy; 2) at the final follow-up two months after treatment; and 3) one year after radiotherapy. Statistical analyses Demographic, tobacco-related, socio-economic and clinical variables were described using tables, boxplots, scatterplots and histograms. Patient characteristics were summarized separately for males and females. Differences in the distribution of the variables were compared by the Pearson χ2-test and a significance level of the estimated p-values was chosen to be 0.05. Associations between the exposure variables and continued smoking were examined using the Pearson χ2-test. For each time point crude odds ratios (ORs) were calculated for all variables and in addition ORs adjusted for age and gender. At first, logistic regression analyses were made stepwise by adding one group of variables at a time to the analysis in prioritized order. ROC-curves and AUC values were used for each multivariable regression model to assess the predictive performance of the model. The clinical variables were non-significant and did not contribute to a noteworthy difference in the AUC values. This was interpreted as not contributing to the overall ability to predict smoking and therefore only the stage of disease, and not symptoms or T- and N-classification, was chosen for the multivariable analyses. The analysis of the distribution of variables was also carried out separately for women and men with essentially very similar results. The additional analyses were conducted for men and women combined

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Figure 2. Follow-up.

assuming gender was not modifying the observed effect of the variables on the outcome.All associations are presented by ORs with 95% confidence intervals (CI). Statistical software package SAS, version 9.4 (SAS Institute, Cary, NC, USA) was used for the analyses. Dealing with missing data The registrations of tobacco use among patients from initiating radiotherapy until the last follow-up in the five-year follow-up program were marked by inconsistency. Patients with registered tobacco use and patients with non-registered tobacco use were compared using χ2-tests to assess if the distribution of the variables differed in the registered and non-registered group. To investigate the robustness of the results from the main analysis, three supplementary analyses based on simple imputation procedures were performed. The Last Observation Carried Forward analysis was used as a method to impute values based on existing data. The second additional analysis was the current smoker approach. No tobacco registration at follow-up was interpreted as currently smoking based on the assumption of ‘no change’, as no smoking cessation intervention was applied. Finally, a multivariable logistic regression analysis was conducted on a sub-population of the 544 patients who were registered with tobacco status at all three endpoints. With χ2 analyses the differences in the distribution of variables between the 544 patients in the sub-population and the remaining part of the laryngeal cancer cohort were determined.

Results In all, 51% of the laryngeal cancer patients registered reported continued smoking at some point during radiotherapy. Only 41% of the registered patients smoked two months after radiotherapy, however, one year after radiotherapy 50% of the tobacco-registered patients were smokers. Eighty-two percent of the patients were men with a median age of 63 years, generally heavy smokers, smoking ⬎ 20 cigarettes per day when diagnosed (61%) with more than 40 pack-years of smoking (55%). All patients received radiotherapy as primary

treatment, for the majority a full curative treatment with a total dose over 60 Gy (96%) fractionated with 6 fractions per week (87%). All descriptive characteristics are summarized in Table I. Being under the age of 60 compared to over 60 was associated with continuous smoking at all three endpoints; during radiotherapy (OR 1.39, CI 1.00– 1.91), two months after (OR 1.59, CI 1.10–2.30) and one year after radiotherapy (OR 1.56, CI 1.06– 2.31) (Table II). Having started smoking before the age of 15 was, likewise, associated with smoking during treatment (OR 1.77, CI 1.32–2.38) two months after treatment (OR 1.51, CI 1.07–2.12) as well as one year after radiotherapy (OR 1.66, CI 1.16–2.37) compared to smoking onset after the age of 15 (Table II). In all analyses, the daily average tobacco consumption before radiotherapy was not associated with being a continuous smoker. After adjusting for age and gender no systematic impact of highest attained education on smoking behavior was observed. Living alone was compared to cohabiting associated with continuous smoking during treatment (OR 1.56, CI 1.13–2.14) as well as two months after treatment (OR 1.45, CI 1.01–2.08) (Table III). However, no association was found one year after treatment. Patients with the lowest disposable income had increased odds for being a continuous smoker during radiotherapy, two months after treatment and at the one-year follow-up (OR 3.69, CI 1.80–7.55) compared to those in the highest income quintile group (Table II). The odds for continuous smoking tended to increase with a declining disposable income level. Among the clinical factors, a linear trend was observed regarding WHO performance status. The better the performance status at time of diagnosis, the lower odds of continued smoking during and after the treatment course. Performance status 2–3 at the time of diagnosis implied the highest odds of continued smoking during the treatment course (OR 3.09, CI 1.71–5.61) compared to performance status 0, and still with a positive association two months after treatment (OR 2.44, CI 1.28–4.64) (Table III). Seventy-four percent of the patients with performance status 2–3 were continuous smokers one year after radiotherapy (OR 3.40, CI 1.34–8.64).

Predictors of continuous tobacco smoking

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Table II. Crude associations and multivariable logistic regression analysis on the association between demographic, tobacco-related, socioeconomic and clinical factors and continuous smoking behavior among laryngeal cancer patients in Denmark, 2000–2010. During radiotherapy Crude OR (n ⫽ 1229)

Gender Men Women Age, years ⬍ 60 ⱖ 60 Number of cig./day Light smoker (⬍ 10) Moderate smoker (10–20) Heavy smoker (⬎ 20) Age started smoking Age 0–15 Age ⬎ 15 Highest attained education Basic school, 7–12 y Vocational training, 10–12 y Higher education, ⬎ 13 y Cohabitation status Living alone Cohabiting Disposable income quintiles 1 (lowest) 2 3 4 5 (highest) Period of diagnosis 2000–2003 2004–2007 2008–2010 Performance status 0 1 2–3 Number of symptoms 1 2 3 Tumor classification T1–T2 T3–T4 Lymph node status N0 N1–N3 Stage I–II III–IV aAdjusted

One year after radiotherapy

Model 1a (n ⫽ 853)

Crude OR (n ⫽ 825) Model 1a (n ⫽ 600)

OR

95% CI

OR

95% CI

OR

95% CI

1.17 1.00

0.88–1.57 Ref

1.21 1.00

0.82–1.78 Ref

1.23 1.00

0.86–1.77 Ref

1.67 1.00

1.04–2.68 Ref

1.21 1.00

0.96–1.52 Ref

1.39 1.00

1.00–1.91 Ref

1.10 1.00

0.83–1.46 Ref

1.56 1.00

1.06–2.31 Ref

1.00 1.01 1.25

Ref 0.68–1.48 0.89–1.76

1.00 0.88 0.95

Ref 0.54–1.43 0.61–1.47

1.00 1.08 1.38

Ref 0.67–1.74 0.90–2.12

1.00 1.09 1.24

Ref 0.60–1.99 0.71–2.15

1.89 1.00

1.48–2.42 Ref

1.77 1.00

1.32–2.38 Ref

1.70 1.00

1.26–2.28 Ref

1.66 1.00

1.16–2.37 Ref

1.00 1.52 1.75

Ref 1.03–2.22 1.18–2.61

1.00 0.90 1.02

Ref 0.55–1.45 0.61–1.71

1.00 0.98 1.48

Ref 0.62–1.53 0.93–2.37

1.00 0.49 0.65

Ref 0.28–0.88 0.35–1.19

2.17 1.00

1.72–2.73 Ref

1.56 1.00

1.13–2.14 Ref

1.85 1.00

1.39–2.46 Ref

1.08 1.00

0.73–1.59 Ref

2.52 2.66 1.42 1.60 1.00

1.68–3.79 1.80–3.94 0.93–2.19 1.01–2.52 Ref

2.21 2.59 1.38 1.72 1.00

1.23–3.98 1.49–4.52 0.78–2.44 0.95–3.11 Ref

3.99 3.18 2.15 1.53 1.00

2.40–6.64 1.94–5.19 1.28–3.64 0.87–2.67 Ref

4.39 4.45 2.00 1.75 1.00

2.16–8.91 2.25–8.81 1.01–3.94 0.86–3.57 Ref

2.00 1.22 1.00

1.49–2.69 0.92–1.62 Ref

1.88 1.23 1.00

1.28–2.77 0.86–1.77 Ref

1.93 1.20 1.00

1.34–2.77 0.84–1.72 Ref

1.47 1.04 1.00

0.92–2.35 0.66–1.63 Ref

1.00 1.58 3.45

Ref 1.21–2.05 2.18–5.46

1.00 1.30 3.09

Ref 0.95–1.80 1.71–5.61

1.00 1.78 3.56

Ref 1.30–2.45 1.70–7.46

1.00 1.62 3.40

Ref 1.09–2.40 1.34–8.64

1.17 1.15 1.00

0.83–1.65 0.78–1.70 Ref

0.90 0.96 1.00

0.56–1.43 0.57–1.63 Ref

1.00 1.08

Ref 0.83–1.40

Not included

1.00 0.93

Ref 0.64–1.33

Not included

1.00 1.22

Ref 0.94–1.57

Not included

1.00 1.08

Ref 0.76–1.54

Not included

1.00 1.25

Ref 0.99–1.58

1.00 1.13

Ref 0.84–1.53

1.00 0.81

Not included

1.00 1.00

Ref 0.74–1.34

Not included

Ref 0.55–1.20

for demographic factors, tobacco factors, socio-economic factors and clinical factors included in the multivariable analysis.

In total 214 patients died within the one-year follow-up period. The patients dying between two endpoints were not included in the following analyses. The patients still being alive but having no smoking status registered one year subsequent to radiotherapy were, at time of diagnosis characterized by lower income, more extensive TNM-stage with several symptoms and a poorer WHO Performance

status compared to those registered with a smoking status. The three analyses pertaining missing data supported the main analyses with similar positive associations and small OR differences. In the final approach with the sub-population of the 544 cases 41–47% were smoking at the tree endpoints. The patients in the subpopulation had lower tumor stages,

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Table III. Variables associated with continuous smoking behavior among laryngeal cancer patients in Denmark, 2000–2010. During RT ORa (95% CI) Gender male vs. female Age, years ⬍ 60 vs. ⬎ 60 Age started smoking ⬍ 15 vs. ⬎ 15 Highest attained education vocational vs. basic Cohabitation status living alone vs. cohabiting Disposable income lowest vs. highest Performance status PS 2–3 vs. PS 0

Two months after RT

p-Value

ORa (95% CI)

p-Value

N.S 1.39 (1.00–1.91) 1.77 (1.32–2.38) N.S.

N.S. 0.05 1.59 (1.10–2.30) 0.0001 1.51 (1.07–2.12) N.S.

0.01 0.02

1.56 (1.13–2.14)

0.01

0.05

2.21 (1.23–3.98) 3.09 (1.71–5.61)

0.004 3.69 (1.80–7.55) 0.0004 2.44 (1.28–4.64)

1.45 (1.01–2.08)

One year after RT ORa (95% CI) 1.67 1.56 1.66 0.49

(1.04–2.68) (1.06–2.31) (1.16–2.37) (0.28–0.88)

p-Value 0.03 0.02 0.01 0.04

N.S.

⬍ 0.0001 4.39 (2.16–8.91) 0.02 3.40 (1.34–8.64)

⬍ 0.0001 0.003

aAdjusted for demographic factors, tobacco factors, socio-economic factors and clinical factors included in the multivariable analysis. RT, radiotherapy.

fewer symptoms, better performance status, more likely to be cohabiting and having a higher income. Still, similar to the main analysis an early smoking onset, low income, living alone and having a poor performance status were associated with continued tobacco use. Discussion In this population-based clinical cohort study of current smokers at the time of diagnosis, 50% continued smoking during the seven weeks of radiation treatment for laryngeal carcinoma and after one year, 50% of those registered with smoking status still smoked. A recent study supports the finding that younger patients are more likely to continue smoking as smoking cessation rates decreased with decreasing age [2]. The study population was, however, characterized by combined cancer types, which makes the group of patients less homogeneous than in this present study. Another previous study supports the finding that an early smoking onset is highly associated with continuous smoking after diagnosis [15]. We found no associations between the average number of cigarettes per day and continuous tobacco use. One previous study [16] found ‘time to first cigarette’ as a measure of nicotine dependence to be associated with long-term smoking abstinence and Danish guidelines for smoking cessation programs also recommend this as an indicator of nicotine dependence [20]. Social inequality has been a topic of growing relevance among head and neck cancer patients and this study also shows that patients living alone or having a low income are more associated with a continuous smoking behavior than those cohabiting or with a higher income. Cohabitation status is an indication of level of social support and social relations in the domestic environment which may influence

the ability to succeed smoking abstinence. Cohabiting patients were similar less likely to smoke in a previous study of head and neck cancer patients, but the sample size was small (n ⫽ 191) [17]. Unfortunately, information on cigarette exposure at home or smoking among friends was not available in this study. This is unfortunate because this information has been known to be a social-environmental factor of significant importance for the smoking status and might affect the benefits of cohabiting [17]. The level of income can reflect the material resources available and other income-related stress factors making it more difficult for people with a low income to quit smoking. The strong association between low income and continuous smoking is not investigated in previous studies. In this study, the level of education was not associated with a continuous smoking behavior. This was surprising, because the educational level might influence the ability to initiate smoking cessation in terms of self-efficacy. In contrast to previous smaller studies, we found no associations between smoking status and TNMclassification, characterizing the extent of the cancer disease [17,21]. It could be anticipated that a higher tumor stage and a subsequent poor prognosis would lead to an indifferent attitude towards tobacco and unhealthy consequences. However, we found an obvious trend that a poor performance status of the patient at the time of diagnosis had a strong association with continuous smoking behavior. No previous studies, to our knowledge, have evaluated the impact of WHO performance status on smoking behavior. The strengths of this clinical cohort study include a one-year follow-up period and a large sample size, which is rare in the existing literature, primarily consisting of small, non-homogenous samples. The present study used data from a unique, nationwide, clinical database, which covers 90–99% of all laryngeal cancer patients in Denmark combined with linkage to several nationwide administrative Danish

Predictors of continuous tobacco smoking registers, minimizing information bias. This adds a unique perspective to the current literature about smoking behaviors after the diagnosis of a smokingrelated cancer disease. The limitation of the study was its historical design with incomplete follow-up data on tobacco at certain endpoints. As a consequence of the repeated measures design 66% of the original cohort being alive was registered with smoking data at follow-up two months and one year after treatment. The smoking status of the patients, being the outcome of interest, was not registered due to factors like patients not attending follow-up, lack of registration to the DAHANCA database or death. The smoking status of the patients in this study were determined through self-report to the oncologist at the follow-ups. There is a risk of the actual tobacco use of the patients being underestimated, however, the percentage of continuous smokers is still high despite the many options for treating tobacco dependence [22]. At time of diagnosis, where the opportunity of behavioral change may be the most favorable, the surrounding hospital setting is probably the only contact with the healthcare system for the laryngeal cancer patient living alone, having a low income, an early smoking onset and a poor performance status [10]. More stratified follow-up programs are needed and an intensive lifestyle intervention for smoking cessation post-diagnosis could be addressed as a part of supportive care by oncology nurses because of their unique position to incorporate tobacco use intervention in clinical cancer care [16] [23]. Social inequalities in cessation rates have been found to be counterbalanced by highly supported cessation interventions [24]. There is a lot of focus today on diminishing the late effects of cancer treatment through new treatment modalities. One simple solution is prophylactic initiatives in supportive care addressing continuous smoking (delete: smoking cessation as a part of supportive care) as there is a substantial need for rehabilitation starting with reducing the adverse health outcomes of smoking [25]. Smoking cessation interventions in cancer care ought to be a priority similar to new treatment modalities as the aim of reducing late effects, ensuring a better health, quality of life and life expectancy for the cancer survivors is the same. Conclusion Fifty percent of patients with laryngeal cancer continue smoking one year after radiotherapy. Our results show that special considerations must be paid to patients with a smoking-related cancer with a poor

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performance status, living alone, having an early smoking onset, being under the age of 60 and having a low income since these factors are highly associated with continuous smoking behavior in the course of treatment and up to one year of follow-up. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References [1] Bellizzi KM, Rowland JH, Jeffery DD, McNeel T. Health behaviors of cancer survivors: Examining opportunities for cancer control intervention. J Clin Oncol 2005;23: 8884–93. [2] Tseng TS, Lin HY, Moody-Thomas S, Martin M, Chen T. Who tended to continue smoking after cancer diagnosis: The national health and nutrition examination survey 1999–2008. BMC Public Health 2012;12:784. [3] Nayan S, Gupta MK, Strychowsky JE, Sommer DD. Smoking cessation interventions and cessation rates in the oncology population: An updated systematic review and meta-analysis. Otolaryngol Head Neck Surg 2013;149:200–11. [4] Globocan. Globocan 2012: Estimated Cancer Incidence, Mortality and Prevalce Worldwide in 2012. Available from: http://globocan iarc fr/Pages/fact_sheets_cancer aspx 2012. [Cited 1st May, 2014]. [5] Danish Head and Neck Cancer Group. Dahanca guidelines and forms. Available from: http://www.dahanca.dk. [Cited 1st May, 2014]. [6] Browman GP, Wong G, Hodson I, Sathya J, Russell R, McAlpine L, et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med 1993;328:159–63. [7] Hoff CM, Grau C, Overgaard J. Effect of smoking on oxygen delivery and outcome in patients treated with radiotherapy for head and neck squamous cell carcinoma – a prospective study. Radiother Oncol 2012;103:38–44. [8] Gillison ML, Zhang Q, Jordan R, Xiao W, Westra WH, Trotti A, et al. Tobacco smoking and increased risk of death and progression for patients with p16-positive and P16-negative oropharyngeal cancer. J Clin Oncol 2012; 30:2102–2111. [9] Zevallos JP, Mallen MJ, Lam CY, Karam-Hage M, Blalock J, Wetter DW, et al. Complications of radiotherapy in laryngopharyngeal cancer: Effects of a prospective smoking cessation program. Cancer 2009;115:4636–44. [10] Thilde Rheinländer, Kræftens Bekæmpelse. Rygestop til kræftpatienter. Et litteraturstudie af effekt og metoder. Available from: http://www cancer dk/NR/rdonlyres/C30B C321-973D-48B3-BBCC-C6EB55B473D0/0/Rygestop_til_ kraeftpatienter_litteraturstudie_ A4_web pdf 2008. [Cited 1st May, 2014]. [11] Jensen K, Jensen AB, Grau C. Smoking has a negative impact upon health related quality of life after treatment for head and neck cancer. Oral Oncol 2007;43:187–92. [12] Kuhn KG, Boesen E, Ross L, Johansen C. Evaluation and outcome of behavioral changes in the rehabilitation of cancer patients: A review. Eur J Cancer 2005;41:216–24. [13] Khuri FR, Kim ES, Lee JJ, Winn RJ, Benner SE, Lippman SM, et al. The impact of smoking status, disease stage, and index tumor site on second primary tumor incidence and tumor recurrence in the head and neck retinoid

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Predictors of continuous tobacco smoking in a clinical cohort study of Danish laryngeal cancer patients smoking before treated with radiotherapy.

Many cancer patients who are smokers when starting cancer therapy continue smoking despite evidence of tobacco smoking as a risk factor for poor treat...
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