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Zach Klaassen: Hi, my name is Zach Klaassen. I'm a urologic oncologist at the Georgia Cancer Center in Augusta, Georgia. Today, we'll be discussing an SUO 2024 presentation, Implementing Smoking Cessation in the Urologic Oncology Setting. I'm pleased to be joined by Dr. Rich Matulewicz, who is a urologic oncologist at Memorial Sloan Kettering Cancer Center. Rich, thanks so much for joining us today.

Richard Matulewicz: It's a pleasure to be here. Thanks so much for the invite, Zach.

Zach Klaassen: Really enjoyed your presentation at SUO. This is impactful stuff. You've done a ton of work in this space. And I'm really excited for you to share a few of the highlights of your presentation.

Richard Matulewicz: Yeah, thanks. I was really fortunate to be invited by the SUO. It was awesome to see some renewed interest in this. And I've been fortunate to work with a lot of really great people, stand on the shoulders of giants from the folks that have done a lot of work in this space beforehand. So just trying to beat the drum, carry the torch, and hopefully, we can all do this a little better because it is important.

Zach Klaassen: Absolutely. It is important.

Richard Matulewicz: So this is an abbreviated version of the talk given at SUO. And again, I was very fortunate to be invited, along with my colleague, Mark Bjurlin, to talk about a number of things in the tobacco-related urologic oncology setting. And my component of this was the implementation of smoking cessation into the urologic oncology setting.

One of the things that I thought was really worth highlighting was that there is this blockbuster new therapy for cancer. And it's something that was recently released and published by the MD Anderson group, which does an excellent job of tobacco use assessment and treatment. And what this blockbuster drug was, was smoking cessation. And it was really an interesting study that they were able to demonstrate that in all comers—so patients treated for all cancers at their center—patients who are able to get enrolled in their tobacco treatment program and then quit had a significant overall survival benefit.

So when you're considering precision oncology therapies, the fact that you're able to increase overall survival in this type of population for almost two years would otherwise be a $1 billion—maybe even $1 trillion—drug in this situation. And one of the things I wanted to contrast was these Kaplan-Meier curves, which really compare the overall survival in patients who did and did not quit smoking with what I think is a revolutionary new protocol in bladder cancer, where we're seeing outcomes never before seen.

This is something that I think people are extremely excited about, really demonstrating a similar overall survival benefit in patients with advanced cancer. And by no means are these direct comparisons or can be generalized to each other. But I thought the parallels here were really remarkable. Because this is presumably a very expensive regimen and certainly worth its weight here. But smoking cessation is something that is quite cost-effective.

I think this is really a good starting point for what we can do for our patients beyond just the surgery, the radiation, and chemotherapy that can really have an impactful overall survival benefit for them. Because really, what we know is that smoking cessation, even at the time of a new diagnosis, does impact many outcomes. And this is very likely what drives these overall survival benefits.

In addition to the improvement in general health, cardiovascular health, respiratory health, small vessel disease—all of these things—specifically in urologic cancers (most studied in bladder cancer), we see people who continue to smoke after their diagnosis have worse surgical outcomes. They have a higher anesthetic risk. This is a population of patients that need to undergo a number of TURBTs, anesthetics, office-based procedures, where the risk of infection and other complications can be really exacerbated by continued smoking.

Same thing with chemotherapy and radiotherapy. A number of really excellent studies have been done showing that actually chemotherapy and radiotherapy work better in patients who quit smoking, which is a remarkable consideration that it has this type of effect modification in the treatments that we give. Putting this all together, this has really been one of the reasons why people have really considered smoking cessation to be the fourth pillar of cancer care, in addition to surgery, radiation, and systemic therapy.

And I think that fourth pillar—and its very well-deserved position in this other triumvirate of treatments we give people—is really well deserved. Because as demonstrated, it does have an overall survival benefit. And the benefit that we have as urologists is we got this because there's ample opportunity to intervene.

This was a study I did with some colleagues at NYU a few years ago, looking at just how often we're seeing patients who are actively smoking in our clinics, and then specifically looking at patients who are actively smoking and also have tobacco-related disease. Really, what we found was that one-third of all visits with urologists are in some way, shape, or form related to tobacco-related GU diagnoses.

And if you boil it down, this comes down to about 1.3 million visits each year with smokers, or those related to tobacco-related diseases being about 400,000 of these, and 150,000 of these specifically being related to GU cancers. So this is a remarkable opportunity for us to intervene, especially given that 20% of patients with a history of GU cancers continue to smoke at the time or after their diagnosis. So we have a real opportunity here.

However, we know patients don't quit. This is a very difficult, relapsing, chronic medical condition. And one of the ways we started to approach this is to try to look at it systematically. And to do this, we put together a determinant evaluation to look at some of the multi-level barriers and facilitators to patients actually quitting smoking. And one of the things we tried to explore were some hypothesis-driven questions. And those were that patients are generally unaware of the connection between their cancer diagnosis and their smoking history.

We thought that education, and certainly physician advice, would be impactful. But we also thought that urologists really weren't doing their part in the outpatient or inpatient setting. By no means am I disparaging my colleagues here, because there's tons of competing priorities and needs in our clinic. And certainly, the active management of other urology diagnoses is paramount. But this all boils down to really patients not getting the evidence-based treatment they need and deserve. And we can't always rely just on the primary care docs to do this because they have very similar, competing, and very important priorities as well.

So exploring some of these things, we did a population-based study using the PATH data set, which is a representative population-based sample of patients, and looking specifically at some of the tobacco-related diseases, practices, beliefs, perceptions, et cetera. And what we found was that among patients who were actively smoking, when considering whether they were aware that smoking causes bladder cancer—certainly compared to whether smoking is harmful, whether it causes other more prevalent and widely known disease processes like lung cancer, head and neck cancer, heart disease—there was a significant disparity in the knowledge and perception that tobacco use was contributorily or causal.

When it comes to bladder cancer, only about 50% of people who actively smoked knew that smoking caused bladder cancer. And when you compare this to some of those other more prevalent disease processes, you're talking 80% to 100% knowledge. And unfortunately, this didn't get all that much better in people that had urologic cancer. Even among patients that had a bladder cancer diagnosis, less than 90% knew that smoking could cause bladder cancer.

So this really demonstrates, at the patient level, what we can do to bridge that gap and educate patients to really understand that smoking may have very well been an important component of their development of bladder cancer. And even now, after the diagnosis, there are benefits to quitting smoking.

Looking at the clinician level, we assessed—using the AUA annual census—a few questions about the perceptions, beliefs, and practices related to tobacco use. And fortunately (and this is different than what it was 10 years ago, when my colleague Dr. Bjurlin first started working on this stuff), 98% of urologists that were queried about this were aware that tobacco use contributes to urologic disease. So this was an encouraging finding.

But only about 60% agreed that assessment and treatment of tobacco use by urologists was important. And this was a recurring theme of things we've seen. Again, urologists have a lot of competing priorities. The thought process is that this may be better left done by other care team members or primary care docs. And this was echoed by the practices, which a similar percentage—about two-thirds or so—did take the step of advising patients to quit but really provided no counseling or medications beyond that.

And that's one of these quality gaps that I think can be addressed in that we're doing maybe a pretty good job of assessing tobacco use, telling patients they should probably quit, but really getting patients evidence-based tobacco treatment in the form of counseling, pharmacotherapy, nicotine replacement therapy—these are the things that really make impactful strides in getting patients to quit. Because again, this is a relapsing, chronic medical condition, and it does require some work and some treatment to get things done.

And the reason why this is important and the reason why taking the next step in all of this is because urologists' advice is very influential. We are very important care team members in not only the patients' cancer journey, but also in their overall health. Urologists are very fortunate to be in a position where we're longitudinal clinicians that can take care of patients from very early on in their lives to very late in their lives. And we're listened to.

One of the studies we looked at with our UCLA colleagues was why patients decided to quit around the time of diagnosis or even after diagnosis. And what we identified was that patients are five times more likely to quit if they are educated and told by their urologist that it's important to quit smoking. Knowing that smoking is related to the diagnosis was also determined in this study to be impactful and a determinant of quitting. So really, I think this echoes that urologists' advice is impactful. And we have an important part of not only shaping specific urology treatment, but also patients' overall health.

So looking at some of the frameworks and taking the next step and really addressing all of this, one of the ones that I use is a simplified approach. It's the AAR model: the Ask, Advise, Refer model. And this should be very palatable to a number of people because it leverages the expertise of our colleagues. And whether you're at a large NCI-designated cancer center that may have a very well-funded and resourced tobacco treatment program, or whether you're in a smaller private practice community hospital where you may not have the benefit of some of these resources, this allows a roadmap and provides a roadmap for doing this.

And the “A” here, the Ask—and the reason why I've highlighted this—is because without the ask, there's really no subsequent steps. If we bury our heads in the sand and don't ask patients if they're using tobacco or continue to smoke, there's no way we're going to take those next steps to intervene and help them understand that quitting smoking will be beneficial to them and get them the evidence-based treatment they need.

So the Ask, Advise, Refer is the framework here. This is something that should be done certainly at all new visits and then at various intervals—any time three to six months throughout follow-up—to see if patients continue to smoke. And every touchpoint with a patient in our offices is an opportunity to query this and also intervene. And going back to the resource setting, this Ask, Advise, Refer framework allows you to really leverage your resources and the expertise around you.

So again, if you're at a well-resourced center, using the tobacco treatment program and putting in a referral to that will be very important. But if not, using a lot of these publicly available resources like 1-800-QUIT-NOW, smokefree.gov—these are resources that will actually reach out to patients, help them get counseling, and even send them medications. So this offloads a little bit of this and may make it a little bit easier to manage some of the other priorities we have in our offices.

So again, tobacco screening—the Ask—this is the most important part. And this is another study that we had done, looking at about 64 million outpatient urology visits and looking at some of the variation in tobacco use screening. And as you can see here, there's a significant variation in how often patients are screened, with some clinicians doing virtually no screening and some doing it 100% of the time. But overall, about 70% of urology visits did include some element of tobacco use screening, which I think is actually fairly good. But in general, that 30%—there's certainly room for improvement.

One of the interesting things we did see in this study was that there was no real difference in the proportion of patients who got screened based on their chief complaint or diagnosis. So it wasn't necessarily that patients coming in with gross hematuria or GU cancer diagnoses were screened more often, despite that association that smoking may have. This was something that seemed like we could really improve in this setting.

So again, I think just boiling this down to the salient points: urologists really are very important providers in the management of general health, and we manage smoking-related diseases quite often. Our advice is incredibly impactful. Patients tend to love their urologist. And it's an opportunity, really, to allow us to leverage the relationship we have with people to make really an impact on patients' general health.

And again, helping a patient quit smoking is perhaps the most impactful intervention we have. Surgery, radiation, chemotherapy—these are all things that potentially cure people. But smoking cessation is something that will go far beyond and impact the patient's health for a very long time.

These evidence-based practices exist. There's meta-analysis, systematic reviews, Cochrane reviews of hundreds of studies really demonstrating that the best practices are getting a patient plugged in with counseling and combination pharmacotherapy in the form of prescription medication and short- and long-term nicotine replacement therapy.

And using the resources and the clinical setting that you have and really adapting these types of frameworks to what is around you in your own practice is the best way to approach this. Understanding your own practices, your own resources, and then making it work from there is the best part about doing this. Automate it. Make it systematic. Make it brainless. And then in general, I think we need to just recognize and continue to recognize—and that's why I was so happy to be invited by the SUO to give this talk this year—the importance of this as a specialty and the impact we can make. And again, quite simply, tobacco treatment is a precision cancer care intervention, and it's a very effective biobehavioral treatment that can really impact patients and improve their overall survival and quality of life.

So again, very appreciative of the SUO and certainly Zach and UroToday for focusing and highlighting all this great work. Very appreciative of my collaborators and colleagues as well.

Zach Klaassen: Rich, thanks so much. Just a great summary of—I know it was a 30-minute talk at the SUO—and you boiled it down to about 10 minutes, which was fantastic, hitting on some great highlights. I mean, we could break down a lot of stuff here. I'm going to focus on a couple areas, which I think you already highlighted, but I want to get a little more in depth with.

It just blows my mind that bladder cancer patients in general do not know that smoking causes bladder cancer. And I think, from a patient level—and I know probably we're going to go with this answer—but what are maybe the top two or three things we can do to educate our patients not only that this is what led to your bladder cancer, but if you stop now, it can help with decreasing recurrence, but also the importance of tobacco cessation?

Richard Matulewicz: Yeah, I mean, that's the crux of a lot of this, actually. And you do need to get a little bit creative because you never want to be judgmental, you never want to be punitive, you never want to make someone feel bad because they're in the situation they're in. What's done is done. And I think, to your point, education—and not blame, and not anything that might cast judgment and hurt the relationship—is the best way of doing it.

So the way I approach it is really to try to integrate smoking cessation as part of the overall treatment plan. I tell them, you've got a new non-muscle invasive bladder cancer or a bladder tumor. We're going to go for a TURBT. We're going to do a re-TURBT. And then we're going to do intravesical therapy. But the other component of this is that we need to help you quit smoking.

Because smoking is going to decrease the risk of recurrence. It's going to improve your ability to get through these multiple anesthetics. It's going to improve your ability to have a good reaction or to avoid some of the adverse effects of any of the treatment that we're going to have to put you through for all of this stuff.

And I try to motivate patients and use it as a goal that they're going to do better if they do this. I'm going to do my part. I'm going to do your surgery as best I possibly can. I'm going to give you the gold standard treatment for all of this stuff. And your component of this is you're going to try to cut down on your smoking. You're going to set a quit date for the date of your TURBT. And we're going to work together to get this done.

And to do that, not only am I going to get you set up with our tobacco treatment program, I'm going to prescribe you some nicotine replacement therapy now. I want you to have a good conversation with our counselors. And you use it to motivate people. You try to interweave it into the treatment plan in general. And you make it part of their overall cancer care plan. And I think, if you set it up like that and you frame it like that, people will understand the importance of it.

A lot of people ask us, what can I do? And I tell them, this is what you can do. And this is going to do well for you beyond just your bladder cancer. You're going to feel better. You're going to breathe better. You're going to walk better. All of these things are going to be beneficial when you quit smoking. So I think using it as the, quote unquote, “teachable moment” and really leveraging a lot that needs to be done around the time of a new diagnosis is the way I approach it.

Zach Klaassen: Yeah, great answer. I think when you look at the data you guys talked about, the urologist is so important. And I think we know that. But to see you guys have that data that really, the most important motivator in quitting from a patient-physician relationship is what the urologist says—it's a challenge to all of us.

I mean, we have busy clinics. We know that we're trying to get through treatment options. You're busy. I'm busy. Everybody listening to this recording has a busy clinic. You've clearly integrated this into your practice. Tell us how we can do this, just a very, very practical standpoint, even in the midst of seeing a huge clinic every week.

Richard Matulewicz: Yeah, it is a challenge. I completely agree. The ways that I think we can best integrate this into our practices are to understand what we have to work with. And just borrowing the AAR framework to break down the components of it, the way we've done this at Memorial is that we try to offload some of the assessment to the patients themselves. So we'll send a query out before a new visit that includes things like social determinants of health, their social history, all of these things that allows the patient, in a very private setting where there's not going to be this judgment like, do you smoke?

You never want to put someone under the gun like that, which allows them to hopefully be forthcoming about their history, but it also allows us to collect that data and have it ready for the new visit. So the other way of doing this is to leverage some of the allied health professionals, some of our ancillary staff. I know there are some clinics that use the MAs or the people that room the patients to query some of these things.

Again, the ask is the most important part of this. So being systematic and collecting this information in a way that it can be used is the first step. And you can do that a number of ways. But understanding your own practices, your own workflows, your own resources at the very beginning is important.

And then again, the advice—this is part of the treatment plan. It does not take a separate 15-minute session to do this. It's something that you can interweave into all components of what you're telling patients. Even when you're counseling about the risks of the operation—which is an essential component of any visit where we're talking about treatment from a surgical perspective—you tell them, you're going to do better with anesthesia. You're going to do better from a wound healing perspective. You have a lower risk of infection if you quit smoking.

And these are all risks that are at the 2% to 3% mark in the operation you're having, but they go up to 6% or 7% if you don't quit smoking. So weaving it in and including it in all of your counseling and including it as a part of that continues to drive the point home that it's important to quit smoking and you're going to do better if you quit smoking. So it's more of a motivational thing than anything.

And then the final thing is probably the biggest challenge. It's the refer component, or it's that bridge to getting patients that evidence-based treatment that really helps people quit much better than just approaching cold turkey or being out on an island. And that's really where you, again, leverage your resources.

So if you're at a big cancer center, almost all of them have some form of tobacco treatment program. There's psychologists, psychiatrists, nurse practitioners, PAs, MDs that are really passionate about this. They're well-trained to do it. They know the medications. They know the motivational counseling approaches. And they do this really well. They certainly do it better than us as urologists because we're not trained to do it.

And that's another gap and something that certainly will hopefully be addressed over time. But we've got a lot to learn, and we've got a lot to worry about. So using the expertise of your colleagues, especially if you're at a resource-rich center, is the best way of doing it. But if not—if you're in solo practice—providing written materials, giving people the 1-800-QUIT-NOW, the smokefree.gov—I pulled this up in my clinic when I've been at the county hospitals as a resident and earlier in my career, and I say, let me print this out. You're going to go to this website, you're going to put in your information, they're going to mail you nicotine gum, they're going to mail you patches, they're going to call you for counseling sessions. That takes a couple of extra minutes. But I think it really demonstrates to the patient too that this is important, it's part of what we want to do for you. And just looking at where you're at and being motivated to do all of this I think is the key.

Zach Klaassen: Yeah, really well said. And just a powerful message, I think. The presentation at SUO was great. I think this interview and this discussion is just amplifying it. Congratulations on all the hard work in this space and for just a great summary of this important topic, without a doubt.

Richard Matulewicz: Thank you, and thank you for highlighting it. Still lots to be done, but I look forward to doing it.

Zach Klaassen: Thanks so much, Rich. Appreciate your time and expertise.

Richard Matulewicz: All right. Thank you so much, Zach.