Lung cancer screening, smoking cessation focus of ed program

Dec. 05--GLASGOW -- Presenters for the Lung Cancer Awareness and Smoking Cessation lunch-and-learn continuing education program Tuesday had a bit of a bad news-good news approach.

The bad news was the cancer rates in Kentucky. The good news items were that lung-cancer screenings are more readily available and multiple options exist to help people stop smoking, both of which were discussed at length. The dangers of e-cigarettes or "vaping" were also discussed.

Kentucky is No. 1 in lung cancer incidence and deaths in the United States, and patients in Kentucky who are diagnosed with lung cancer are usually diagnosed at a later stage than in some other areas of the country, said Melanie Isbell, a nurse practitioner who works in oncology and hematology at T.J. Health Pavilion, where the program took place. Kentucky also has the highest rate of colorectal cancer, overall cancer death rate and cancer incidence rate for all types of cancers, she said.

Cancer kills 8.2 million people every year, with the probability being slightly higher among men than women, she said.

Through T.J. Regional Health's entities, an average of 3,435 with a cancer diagnosis are treated annually, Isbell said.

The hospital is accredited by the Commission on Cancer itself, but it also has partnered with the University of Kentucky HealthCare Markey Cancer Center, the commonwealth's only National Cancer Institute-designated center, to further boost the care options available to cancer patients.

"When we talk about prevention and ways to reduce these numbers of a one-in-three chance of getting cancer, things we talk about are prevention and early detection. For patients with lung cancer, because a lot of them don't have symptoms early on ..., sometimes lung cancer's found later, so we want to take a look at ways that we can do screening to help find lung cancer earlier.

The low-dose computed tomography lung screening program started at the hospital in 2016, with 576 participants so far.

"It's a scan, and it's usually easy and painless. It's noninvasive. It takes approximately five minutes to perform; it takes about the same amount of time as a chest x-ray, but it's more sensitive to areas in the lungs where we need to see more detail," Isbell said. "It's a minimal radiation exposure, about the same as a mammogram."

Several criteria have to be met, though for insurance to cover the screening. Those include being a current smoker or former smoker who has quit within the past 15 years, being ages 55 to 77, being asymptomatic, and meeting certain other thresholds regarding smoking history, she said.

From March 1, 2016, through March 30, 2018, of those with a possible issue identified, 39 were deemed benign and are resuming annual follow-ups, 21 are monitoring with in-between follow-ups or refused confirmation or biopsy, and eight had a malignancy (cancer), Isbell said.

"In this area of Kentucky, and Kentucky in general, it's a large smoking population, which is the No. 1 risk factor for lung cancer, so this is the way that we can screen those patients who haven't quit or have only recently quit," she said.

With that, she turned over the program to Laura Howard, a nurse practitioner who works in pulmonology, who also started with a few statistics, e.g. cigarette smoking is the leading cause of preventable disease and death in the United States, and, as of 2015, about 15 of every 100 U.S. adults smoked, but that had declined from nearly 21 of every 100 in 2005. The current goal is to get that to 12 percent by 2020, but Kentucky and West Virginia have the highest rates of smokers, with Kentucky's rate being 26 percent.

She said that about a year ago, "we came together and decided that we needed to offer more to our patients in their efforts to quit smoking."

Howard pointed out that, of the hundreds of chemicals found in cigarettes, 69 are known carcinogens -- substances that tend to cause cancer.

"Just to read over that list makes me want to cringe," Howard said, pointing to the screen that displayed a list including acetone, found in nail polish remover; ammonia, found in toilet cleaner; arsenic, found in rat poison; butane, found in lighter fluid; carbon monoxide, which is in car exhaust; DDT, an insecticide; hydrogen cyanide, gas chamber poison; mercury, the chemical used in thermometers; methanol, found in rocket fuel; nitrous oxide, found in disinfectants; tar, street paving material; vinyl chloride, used to make PVC pipe; and ethanol, which is in alcohol.

She said a lot of patients think e-cigs are a safer option, but they have 28 known carcinogens, including nicotine and formaldehyde; popcorn lung -- a constriction of lung tissue -- is a documented hazard believed to occur from the flavoring; and they decrease lung function and increase airway resistance.

"The effect on the lung tissue is still the same," no matter what is being smoked/inhaled, she said. "[E-cigs are] still going to lead to issues with asthma and [chronic obstructive pulmonary disease]."

Howard also spoke about nicotine -- one of the most addictive legal chemical substances available -- and its effects on the "reward centers" of the brain.

"When you light a cigarette, the nicotine hits those dopamine receptors in the brain quicker than heroin. It is very quick onset, and it very quickly stimulates those receptors that say, 'This feels good; I want to continue to do it ...,'" she said. "Because the onset of nicotine is so fast ..., the offset, or the down side of it, is just as fast. So when people are smoking a cigarette, they're stimulated to say, 'This feels good, and I'm going to keep smoking.' But it's the sudden downfall of the nicotine that is actually stimulating them to make them want the next cigarette. ... It's a sharp uptake, but it's also a sharp decline."

Help?

"Everybody has an opinion about what the most effective way to quit smoking is," Howard said. "I'm going to tell you ..., there is no one way. It's mind over matter and you have to be supportive of people and what they feel is going to work for them."

Though 4 percent to 7 percent of smokers quit spontaneously -- cold turkey -- each year, the success rate grows progressively higher if an individual talks with a healthcare provider about the effort, takes medication or participates in an organized program of some kind.

Of the roughly 70 percent of smokers who see healthcare providers routinely, about 70 percent of those express a desire to quit, and physicians are supposed to address smoking on every visit, but in the course of their visit with patients, time is limited.

Just having a doctor tell someone they need to quit "is not going to cut it," she said

Because "a huge number" of the patients who come to their practice smoke, she and the other pulmonary nurse practitioner started offering one-on-one counseling sessions of typically 15 to 30 minutes with those who want to quit. They provide information about resources, methods and tips for smoking cessation and assistance moving forward with the effort. They suggest informing family and friends of the intent to quit; throwing away cigarettes, ashtrays and lighters; avoiding alcohol or other triggers for smoking; developing a plan; setting a quit date; and booking a follow-up appointment within two weeks.

They help them set goals each visit, e.g. postponing that first cigarette of the day by 10 minutes or not smoking in the car.

"Smoking is an addiction in the brain, but it's also a habitual problem," Howard said. "Nicotine replacement therapy, Chantix, Wellbutrin, those things are going to work on that nicotine addiction, but you yourself have to work on the habit. The medication's not going to change the habit, so you have to change the habit and the routine."

As more and more goals are met, a person's motivation and confidence in the ability to quit completely generally increase as well, she said.

Assistance with the withdrawal symptoms and/or medication side effects is also part of the counseling process, she said.

She said some people do will with the individual approach, while others do better in a group setting, like a Freedom From Smoking Courses, which the T.J. Samson education department offers free about three times a year.

The groups meet weekly for seven weeks, except during the fourth week -- the stop-smoking week -- when they meet twice. The next new class is scheduled to start in early January.

One of the main points Howard emphasized is to let people know it's not expected to be an overnight process -- more like a few months, especially with certain methods -- and it's not uncommon to not be successful the first time.

"It typically takes people eight to 11 attempts to actually quit smoking," Howard said.

With that, she discussed in some detail various therapies designed to help with the process, including dosages, duration, side effects, when not advised and success rates. Those methods included nicotine patches, gum, inhaler or lozenges; the medication Wellbutrin SR, the generic for which is bupropion; and Chantix, the generic for which is varenicline.

Hypnotherapy and acupuncture are additional methods that some try, and she said she had some information on those, but it wasn't as extensive.

Howard also touched briefly on insurance requirements for smoking cessation, but the exact coverage varies widely, she said.

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