October 11, 2023
Dr. Monica Khattak
Tobacco use remains the leading cause of preventable disease and deaths in the US. An estimated 34 million US adults, and 1.3 billion people worldwide, smoke. With approximately 8 million smoking-related deaths globally each year, cancer is the leading cause of these deaths.1
The ACS Commission on Cancer (CoC) recently announced new initiatives to promote smoking cessation within US cancer hospitals—Just ASK and the complementary Beyond ASK.
ACS CoC Chair Timothy W. Mullett, MD, MBA, FACS, participated in a White House forum focused on expanding equitable access to smoking cessation programs and reducing the burden of tobacco-related cancers, which also are part of President Biden’s Cancer Moonshot initiative. Cancer Moonshot is a national effort to reduce deaths from cancer by 50% within 25 years and improve quality of life for people with cancer and cancer survivors. In addition, because smoking leads to approximately 30% of cancer deaths in the US, the initiative will focus on increasing the number of people who quit smoking.
Smoking impacts surgical care across all specialties, with breast cancer being the most common cancer among women globally. This viewpoint article focuses on recommendations for the care of patients who smoke and have breast diseases.
Tobacco contains known mammary carcinogens such as polycyclic aromatic hydrocarbons and aromatic amines that are stored in breast adipose tissue and carry a known anti-estrogenic effect that can induce early menopause.1 An estimated 90% of breast cancer cases are influenced by environmental factors and lifestyle.
Both current and former female smokers face a significantly increased risk of breast disease and breast cancer. Women who start smoking at an early age and before their first childbirth are at an increased risk of malignancy. Overall, the carcinogenic risk of smoking is greatest in premenopausal women.2
Smoking cessation around the diagnosis of breast cancer should be encouraged, as extensive research demonstrates the most powerful incentive for a smoker to quit is after the new diagnosis of heart disease or cancer.
One study noted that slightly less than 75% of lung cancer patients quit smoking by their surgery dates and nearly half (48.9%) continued to abstain from smoking 1 year postoperatively, highlighting the power of the teachable moment of a cancer diagnosis to convince a smoker to quit.3
Smoking-related illnesses cost the US more than $600 billion a year in healthcare expenditures and lost productivity from smoking-related illnesses and premature death.4 Smoking is linked to chronic health conditions, including coronary artery disease, cerebrovascular disease, and chronic obstructive pulmonary disease, that adversely impact perioperative surgical outcomes.
An ACS National Surgical Quality Improvement Program database study demonstrated that current smokers have higher odds of overall, pulmonary, wound, and septic/shock complications following most cardiovascular and oncologic operations.5 Another meta-analysis of postoperative complications found that surgical site infection, dehiscence, and delayed healing occurred twice as frequently in smokers undergoing surgery.6
Cigarette smoke contains nicotine (a vasoconstrictor), carbon monoxide, and hydrogen cyanide, which impair wound healing by producing tissue hypoxia. In patients undergoing simple mastectomy, modified radical mastectomy, or breast-conserving surgery, active smoking is an independent risk factor for wound-healing complications, including skin flap necrosis, epidermolysis, and surgical site infections.6
In a retrospective study of more than 1,100 patients, 14.8% of smokers had a wound complication following mastectomy compared to 7.1% of nonsmokers.7 The Cleveland Clinic has reported greater overall complication rates in smokers undergoing postmastectomy breast reconstruction.8
For smokers who undergo autologous repair with flap reconstruction, complications included partial flap necrosis, abdominal wall necrosis, hernia formation, fat necrosis, and increased revision rates for reshaping of scars.8 This is consistent with recent studies that show higher rates of wound complications in active and previous smokers undergoing breast prosthesis.6
For these reasons, many plastic surgeons delay autologous reconstruction until patients quit smoking, despite immediate reconstruction being more convenient for patients. Smoking cessation in the perioperative period is associated with improved survival in breast cancer patients across all tumor stages.9
Figure. Just ASK: Beyond ASK
Smoking cessation 4 to 8 weeks before elective surgery can result in improved perioperative pulmonary function and wound healing.6 In the UK, patients often are directed to undergo a smoking cessation course for several weeks before undergoing elective surgery. But given the concern of cancer spread, a lengthy time delay to achieve the ideal 4-to-8-week window for smoking cessation may not be realistic.
Proceeding directly to resection of the breast cancer may be more appropriate, and the key question then arises whether plastic surgery reconstruction should be offered immediately/ simultaneously or deferred to a second operation. As the second operation is elective, there is time for surgeons to counsel patients to stop smoking in an effort to reduce mortality and healthcare costs. Given the long-term health benefit from smoking cessation, smokers who undergo immediate definitive reconstruction should be referred for postoperative cessation treatment and counseling.
The power of nicotine addiction makes smoking cessation difficult, often requiring multiple quit attempts to succeed. Approximately 70% of smokers want to quit, although women may be less motivated to quit smoking.1,8
Traditionally, smoking cessation efforts on the part of surgeons have emphasized the Ask-Advise-Refer approach as part of an expanded social history assessment of tobacco use. The hallmarks are (see Figure):
For surgeons interested in assisting their patients with quitting, a variety of smoking cessation therapies are available, ranging from medications and nicotine replacement therapies, cognitive behavioral therapies, and holistic approaches, including hypnotherapy, yoga, mindfulness meditation, and acupuncture. Most cessation interventions are associated with durable quit rates under 10%, but combined behavioral counseling and pharmacotherapy can be more effective.1 Patients who are prompted multiple times with pamphlets, surveys, and by the healthcare team, were more likely to quit.6
The ACS Quit Smoking Before Surgery Program, which makes available resources to help surgeons support smoking cessation for their patients, includes a Quit Smoking Before Your Operation brochure that details treatment options and an action plan. In addition, Beyond ASK—the quality improvement project sponsored by the ACS Cancer Programs—offers a “road map” to smoking cessation along with a list of resources available to help patients quit smoking.
At the Cleveland Clinic, plastic surgeons screen for smoking status during the preoperative consultation. Smokers are counseled about the increased risk for postoperative complications, provided with educational smoking cessation materials, and connected to cessation programs either via their primary care office or other services. Documenting this discussion in the medical record invites patients to participate further in their care. A urinary cotinine level is obtained to establish a baseline, with repeat testing performed at subsequent visits.
For patients who wish to undergo autologous reconstruction, an elective operation is deferred 1 to 3 months until smoking cessation is achieved. Due to the need for urgent oncologic treatment, the placement of tissue expanders at the initial operation is not delayed, regardless of smoking status.
When patients return for follow-up, their smoking status is monitored through urinary cotinine levels. If patients demonstrate motivation and adherence to smoking cessation, they can proceed with autologous breast reconstruction. Patients are encouraged to continue cessation postoperatively to optimize cancer outcomes and their overall health.
The ACS CoC has introduced two initiatives that surgeons can incorporate into their practices to help curb the deadly toll of tobacco use. At the national level, the ACS CoC and National Accreditation Program for Breast Centers have partnered in Just ASK—an elective quality improvement project focused on strengthening evidence-based care across participating programs by leveraging existing resources to address smoking by ASKing all newly diagnosed cancer patients about their smoking status.
This program seeks to build a programs’ capacity to offer cessation assistance to newly diagnosed cancer patients who report currently smoking.
The 2023 goal for Beyond ASK is to increase the number of patients who are offered quitting assistance by at least 20% over baseline or maintain assistance to identified patients at over 90% through the year. Early results have underscored the value of using electronic health records for data collection, capture, reporting, and action as highlighted by the Cleveland Clinic experience.
Surgeons can harness the teachable moment of an upcoming breast cancer operation to emphasize that preoperative smoking cessation can increase the success of the upcoming operation and enhance overall long-term cancer survival.
The thoughts and opinions expressed in this viewpoint article are solely those of the authors and do not necessarily reflect those of the ACS.
Dr. Monica Khattak is a fourth-year general surgery resident at the Cleveland Clinic South Pointe Hospital in Warrensville Heights, OH.