By Sara Bondell - January 30, 2023
EDITOR’S NOTE: In honor of National Women Physician Day on Feb. 3, Moffitt Cancer Center’s Women in Oncology group is highlighting the ways women physicians and researchers are contributing to the prevention and cure of cancer.
In early 2022, President Joe Biden announced the relaunch of the Cancer Moonshot initiative with the goals of reducing the cancer death rate by half within 25 years and improving the lives of patients and survivors. A key component of the initiative is to expand the use of proven cancer prevention and early detection strategies.
Millions of Americans, especially those among medically underserved populations, are at high risk for cancers that have proven prevention and screening strategies in place. Although breast, cervical, colorectal and lung cancers all have nationally recognized screening programs, lung cancer screening participation significantly lags behind.
According to the National Cancer Institute’s Cancer Trends Progress Report, the most recent data available shows 76.4% of women ages 50 to 74 had a mammogram within the past two years, 73.5% of women ages 21 to 65 were up-to-date with cervical cancer screening and 67.1% of adults ages 50 to 75 had received colon cancer screening under current guidelines.
However, only 5.7% of those at high risk for lung cancer are screened, according to the American Lung Association’s State of Lung Cancer 2020 Report.
In 2021, the U.S. Preventive Services Task Force expanded lung screening guidelines to include more people. Annual screening with a low-dose CT scan is now recommended for adults ages 50 to 80 who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Early detection by low-dose CT scans can decrease lung cancer mortality by up to 20% among high-risk populations.
“If everyone who is eligible to undergo lung cancer screening actually had the screening done, 60,000 lives per year would be saved,” said Jhanelle Gray, MD, chair of the Thoracic Oncology Department at Moffitt Cancer Center. “That’s a significant amount, and when you look at the goals of the Cancer Moonshot project, this to me is low-hanging fruit. This is something we have to do.”
Detecting Cancer Early
Efforts are already in motion at Moffitt to improve lung cancer screening and prevention. Thoracic surgeon Lary Robinson, MD, leads the Lung Early Detection Program, which is dedicated to finding lung cancers earlier. Within that program is the Lung Cancer Screening Program, which facilitates all screenings; the Pulmonary Nodule Program, which is for patients who have had an abnormality identified on a screening; and the Surveillance Clinic, which is for lung cancer survivors who are also at risk for secondary cancers.
"The earlier we can detect lung cancer, the higher your chance of cure is."- Jhanelle Gray, MD, Thoracic Oncology Department
“All of these programs use very similar processes and procedures, like the low-dose CT scan, to help follow patients and promote early detection,” Gray said. “This is critically important because the earlier we can detect lung cancer, the higher your chance of cure is.”
The five-year survival rate for lung cancer is 56% for cases detected when the disease is still localized. However, only 16% of lung cancers are diagnosed at an early stage. For cases where the cancer has spread to other organs, the five-year survival rate is only 5%.
To increase the number of eligible individuals who undergo lung screening, thoracic physicians and researchers are trying to identify the barriers and solutions to overcome them. This includes creating shared documentation in the electronic health record to make scheduling screenings easier, increasing access to underserved populations, working to end the need for prior authorization for screening, eliminating stigma, and increasing awareness among communities and primary care providers.
U.S. Rep. Kathy Castor has requested $2.3 million in the fiscal year 2023 budget for Moffitt to purchase a mobile screening unit to reach underserved populations. Meanwhile, the Lung and Thoracic Tumor Education Program is working on developing new partnerships and appropriate educational tools that not only target current and former smokers to come in for first-time scans, but to keep them coming back annually.
“We want to eliminate any negative reassurance,” Gray said. “For example, some may say, ‘I smoked, I received a negative CT scan, so I can continue smoking.’ This is not the correct thinking. Those at risk must continue to have annual low-dose CT scans and quit smoking.”
The team is also looking into setting up an electronic system that can send out reminders to patients and create an opportunity to easily schedule annual scans.
Smoking Cessation for Patients
Smoking is the main cause of lung cancer and contributes to 80% to 90% of lung cancer deaths in women and men, respectively. Men who smoke are 23 times more likely to develop lung cancer and women are 13 times more likely compared to never-smokers. Exposure to secondhand smoke can also increase risk for lung cancer.
The National Cancer Institute has awarded funding to several projects that align with the Cancer Moonshot’s recommendation to expand screening and prevention strategies, including the Cancer Center Cessation Initiative. The goal is to develop sustainable and effective tobacco cessation programs for patients with cancer while also evaluating approaches and outcomes.
Moffitt is one of the NCI-designated cancer centers to receive funding. Vani Simmons, PhD, co-director of Moffitt’s Tobacco Research and Intervention Program, is leading the two-year, $500,000 project aimed at building infrastructure to provide Moffitt patients access to smoking cessation resources. Studies show up to two-thirds of patients continue to smoke even after their cancer diagnosis.
"Some cancer patients think it’s too late to quit smoking once they’ve been diagnosed with cancer. However, there are a number of adverse outcomes that are related to continued smoking."- Vani Simmons, PhD, Tobacco Research and Intervention Program
“Some cancer patients think it’s too late to quit smoking once they’ve been diagnosed with cancer,” Simmons said. “However, there are a number of adverse outcomes that are related to continued smoking, including cancer treatment being less effective, increased risk of secondary cancers and greater side effects from treatment.”
As part of the initiative, Moffitt developed an automated e-referral system to the Tobacco Free Florida Quitline. The goal is to ask every patient about their smoking history, advise current smokers to quit and refer them to Moffitt’s tobacco treatment specialists or to other resources such as the quitline.
Simmons and the Tobacco Research and Intervention Program faculty are also applying for large grants to advance smoking cessation research with patients. Underreporting is a major challenge because of the stigma surrounding smoking, so they want to investigate better ways to ask patients about their smoking history and to develop more innovative ways to help them quit.
Research shows that while the state tobacco quitline is a no-cost treatment resource, the number of patients referred to the quitline and percentage of smokers who actually get assistance is remarkably low.
“In terms of future directions, our team is interested in leveraging digital technology to increase the proportion of patients who are asked about their smoking,” Simmons said. “We think using a digital method may result in patients feeling more comfortable reporting their smoking, and it can also take some burden off of the providers.”
Researchers at Moffitt are also conducting research on low-nicotine cigarettes, how to best motivate patients with nonsmoking-related cancers to quit, and how to bring smoking cessation resources to racial and ethnic minorities. While Spanish speakers are the largest minority group in the country, there are surprisingly few evidence-based Spanish-language materials available for smokers. A large, randomized Moffitt study with more than 1,400 Spanish-speaking smokers demonstrated the efficacy of a self-help smoking cessation program culturally adapted for Hispanics.
“Our next step for that line of research is to look into how to extend the reach of our work by translating and adapting our written intervention into a mobile health intervention,” Simmons said.
Need to Quit? There’s an App for That
While the national smoking average sits at around 12%, Jennifer Vidrine, PhD, MS, assistant center director for Research Strategic Partnerships, and Damon Vidrine, DrPH, MS, interim chair of the Health Outcomes and Behavior Department, conducted a pilot study in Oklahoma and found that about 50% of food bank clients they surveyed reported current smoking. Many did not have access to transportation and smoking cessation resources. But when offered the opportunity to participate in a pilot study evaluating a prototype of a fully automated, personally tailored, smartphone-delivered intervention for tobacco cessation at food distribution sites, a high proportion of smokers enrolled.
Jennifer and Damon Vidrine were awarded a five-year grant from the NCI to evaluate the efficacy of this novel treatment approach in a randomized controlled trial. Upon coming to Moffitt three years ago, the Vidrines worked with the cancer center’s Office of Community Outreach, Engagement and Equity and the University of South Florida’s Center for the Advancement of Food Security & Healthy Communities to develop a partnership with Feeding Tampa Bay to support recruitment for their study.
“We are getting people enrolled in the study at that initial in-person interaction when they are picking up their food,” Jennifer Vidrine said. “They get a 10-week supply of combination nicotine replacement therapy, and we compensate them for their time. We follow them for a full year, and if they complete every single assessment, they can earn up to $510. That is a meaningful amount of money for those who are struggling financially.”
"As smoking has become more and more stigmatized, individuals are sometimes reluctant to admit to smoking, which can make it challenging for them to get help with quitting."- Jennifer Vidrine, PhD, Research Strategic Partnerships
The mobile app offers 12 weekly smoking cessation treatment videos in English or Spanish that are tailored to each smoker’s unique needs, based on a series of questions they answer. The videos can be watched on demand and then rewatched later, and the app has a proven benefit that a manned quitline doesn’t: It can be accessed 24/7. Studies also show gamification, such as receiving badges or trophies for completing tasks on an app, increases engagement.
The goal is to enroll 500 people into the app study within the next two years.
“As smoking has become more and more stigmatized, individuals are sometimes reluctant to admit to smoking, which can make it challenging for them to get help with quitting,” Jennifer Vidrine said. “Through partnering with Feeding Tampa Bay, we can reach these individuals and offer help with the support of a trusted and well-respected community organization that they have already come to trust and rely on for assistance with food insecurity.”
Saving More Lives
Now that the cancer center has established ways to increase lung cancer screenings, launched research projects and identified digital tools to help smokers quit, it’s time to gain national support. In September 2022, Gray and other lung cancer screening advocates, patients and researchers traveled to Washington, D.C., to meet with congressional members and ask for support to increase access to and improve education about lung cancer screening.
“We got some really important questions on how to make this move forward in partnership,” Gray said. “We have drafted a policy letter with multiple items such as potential barriers and how to address them. Each one of the items we have on there can be its own policy that a representative can sponsor and help support as a bill.”
Targeting lung cancer screenings for current or former smokers is just the beginning, and lung cancer advocates are also hoping to lay the groundwork for federal support for screening for nonsmokers in the future. About 15% of patients who develop lung cancer have never smoked, so it’s also important to study other exposure risk factors like radon and air pollution and develop tests to identify genetic mutations that can cause cancer.
“The best-case scenario is that we are all working in partnership across every field to understand these patient populations and focus on increasing screening rates with the ultimate goal of saving lives,” Gray said.