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When staff from Journal of Oncology Practice contacted me a month or so ago to inform me that the theme of this edition would be the Cancer Prevention Policy Statement, and that they wanted me to focus on smoking cessation, I thought that this column would be a snap to compose. You see, my mother died of head and neck cancer in 1994, after a lifetime of addiction to tobacco. She was only 62, and left behind a husband who is growing old without her, children who miss her, and grandchildren who barely remember her. I could turn this column into a personal rant against the tobacco industry, but that column has been written many times by others. I could recall poignant moments from her life, but that would seem a bit self-serving. Instead, I thought I would focus on the intense addiction that would ultimately take her life, and think about our opportunities to help others avoid this fate.
Like many others of her generation, Mom began smoking as a young woman in the late 1940s or early 1950s when smoking was very much normative behavior, and in fact, socially encouraged. Though some no doubt were aware of the dangers, we really didn't see major public efforts to curb smoking until the mid-1960s, and by then nearly an entire generation was hooked. By the time I entered college in the early 1970s many were “kicking the habit”; but others, like Mom, never found the means to do so. I'm sure her physicians likely encouraged her to quit, but encouragement was the only tool available to them. My regular rants against smoking, of course, caused only undesirable tension in our home. She always maintained that she could quit if she wanted to, but it never happened and the inevitable came to pass.
Today, we are armed with more sophisticated data and aids to help patients stop smoking, but tobacco remains highly addictive, and tobacco-related illness remains a leading killer worldwide. Clearly, more needs to be done to keep people from becoming smokers and to help those who already smoke to stop smoking. ASCO long ago took an antitobacco stand, and with the publication of the Cancer Prevention Policy Statement, takes the battle a step further. This statement is reflective of the current ASCO Strategic Plan, which includes advocacy for “worldwide reduction and ultimate elimination of tobacco products and exposure to environmental tobacco smoke.”
Oncologists are charged to use all “episodes of care” as teachable moments, and to help their patients become tobacco-free. Indeed, I have seen this succeed in my own practice. Surviving a malignancy (tobacco related or not, it seems) really does seem to open a person's eyes, and causes them to take stock of all areas of their lives. Survivorship is often associated with dietary change, weight loss, initiation of exercise programs, and, yes, even smoking cessation. These processes can be facilitated and encouraged by the oncologist, who, in the eyes of many patients and family members, has been elevated to a pedestal afforded to very few. It is vitally important to take advantage of this powerful therapeutic relationship at these teachable moments, when it is possible to affect major positive lifestyle changes.
How can the Clinical Practice Committee help? The Cancer Prevention Committee has described several barriers to implementation of prevention counseling. One of the largest, it seems, is that of providing appropriate reimbursement to the physician who provides cancer prevention counseling services. Although there are Current Procedural Terminology codes in place for tobacco cessation counseling, and the Centers for Medicare and Medicaid Services reimburses for this service, many physicians are either unaware of the existence of these codes, or choose not to use them, for they are seldom reported by oncologists. Educational efforts may be required to make oncologists more aware. Existing evaluation and management codes may not adequately describe the work involved in providing cancer prevention counseling services, and proposals for new Current Procedural Terminology codes are being considered. As the chair of the Clinical Practice Committee, I have participated in recent conference calls related to reimbursement issues surrounding cancer prevention services, and will continue to work with the Cancer Prevention Committee to do what I can to remove barriers that stand in the way of oncologists who are committed to this important work.
Oncologists have an obligation to use every possible opportunity to engage in cancer prevention activities. I know that I regularly get up onto my antitobacco soapbox. I realize that in some cases my ministrations fall on deaf ears, but that doesn't stop me from trying. It won't bring Mom back, but it seems like the least I can do.