Feasibility of Mobile and Sensor Technology for Remote Monitoring in Cancer Care and Prevention

Objectives. Remote monitoring (RM) of health-related outcomes may optimize cancer care and prevention outside of clinic settings. CYCORE is a software-based system for collection and analyses of sensor and mobile data. We evaluated CYCORE's feasibility in studies assessing: (1) physical functioning in colorectal cancer (CRC) patients; (2) swallowing exercise adherence in head and neck cancer (HNC) patients during radiation therapy; and (3) tobacco use in cancer survivors post-tobacco treatment (TTP). Methods. Participants completed RM: for CRC, blood pressure, activity, GPS; for HNC, video of swallowing exercises; for TTP, expired carbon monoxide. Patient-reported outcomes were assessed daily. Results. For CRC, HNC and TTP, respectively, 50, 37, and 50 participants achieved 96%, 84%, 96% completion rates. Also, 91-100% rated ease and self-efficacy as highly favorable, 72-100% gave equivalent ratings for overall satisfaction, 72-93% had low/no data privacy concerns. Conclusion. RM was highly feasible and acceptable for patients across diverse use cases.

Considering Systemic Barriers to Treating Tobacco Use in Clinical Settings in the United States

The Comorbidity Workgroup of the Tobacco Treatment Research Network, within the Society for Research on Nicotine and Tobacco, previously highlighted the need to provide tobacco treatment to patients diagnosed with comorbid physical and mental health conditions. Yet, systemic barriers in the United States health care system prevent many patients who present for medical treatment from getting the evidence-based tobacco treatment that they need. The identified barriers include insufficient training in the epidemiologic impact of tobacco use, related disorders, and pharmacological and behavioral treatment approaches; misunderstanding among clinicians about the effectiveness of tobacco treatment; lack of therapeutic support from clinical staff; insufficient use of health information technology to improve tobacco use identification and treatment; and limited time and reimbursement for clinicians to provide treatment. We highlight three vignettes demonstrating the complexities of practical barriers at the health care system level. We consider each of the barriers in turn and discuss evidence-based strategies that could be implemented in the clinical care of patients with comorbid conditions. In addition, in the absence of compelling data to guide implementation approaches, we offer suggestions for potential strategies and avenues for future research. Implications: Three vignettes highlighted in this article illustrate some systemic barriers to providing tobacco treatment for patients being treated for comorbid conditions. We explore the barriers to tobacco treatment and offer suggestions for changes in training, health care systems, clinical workflow, and payment systems that could enhance the reach and the quality of tobacco treatment within the US health care system.

The impact of smoking cessation on breast cancer patients’ survival

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Background: Breast cancer remains to be one of the highest causes of cancer mortality amongst females globally, second only to lung cancer. Smoking is strongly associated with increased all-cause mortality, including breast cancer related death. It has also been shown to have a negative influence on long-term survival after successful breast cancer treatment. Prior studies have shown that smoking cessation may lead to improved prognosis and better outcomes. Methods: This is a retrospective cohort study of breast cancer patients who were identified as smokers, some of who were referred to the tobacco treatment program (TTP) located at MD Anderson Cancer Center. TTP includes careful patient screening, motivational counseling, and pharmacotherapy. We complemented the original data collected by conducting in-depth chart reviews to extract data including patient demographics, date of diagnosis, stage of cancer, smoking status, duration of abstinence and dates of follow-up or death. We then examined associations between smoking status and survival status using multinomial regression models adjusting for biomarkers of disease and personal characteristics. Results: Among all breast cancer patients (N = 31069), we identified those who are smokers (n = 2320) by matching the TTP database with smoking status from our institutional electronic health records. Of those, 740 patients were referred to TTP. Amongst these, 242 patients quit smoking and remained abstinent at the 9 month follow-up. Compared with non-abstainers, those who quit were more likely to be alive with no evidence of disease during the observation time (RR = 1.62, p = 0.045). When analyzed at different stages, the RR went from 1.35 (p = 0.42) to 2.77 (p = 0.34) for stages 3 and 1, respectively. Although the strength of this relationship varied among disease stage, the direction of the relationship remain consistent. Conclusions: Our data shows that smoking cessation is associated with improved survival status amongst breast cancer survivors across all stages. Comprehensive smoking cessation services may improve survivorship when started as early as the time of diagnosis. Further analysis of the association between smoking cessation and other associated medical outcomes will be conducted to further determine the specific impact of cessation programs.

Impact of smoking cessation in locally advanced head and neck cancers undergoing radiation

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Background: Multiple studies have highlighted the negative outcomes associated with smoking during radiation (XRT) for locally advanced head and neck cancer. However, there has been little research investigating the potential benefit of smoking cessation prior to XRT and the effect on response rates, relapse, distant metastases, secondary malignancies, and overall survival. Methods: We reviewed 680 patients at the University of Texas MD Anderson Cancer Center from 2005-2012 with locally advanced head and neck cancer undergoing XRT. 127 were referred to the Tobacco Treatment Program (TTP) based on provider referrals, self-referrals, or screening. Of those referred and retrospectively reviewed, 89 were identified as current smokers and 41 of them participated in the TTP for smoking cessation. Among these 89 patients, 50 patients (18 participated in the TTP) quit smoking prior to XRT and 29 patients (19 participated in the TTP) continued to smoke, which are referred to as Quitters and Smokers, respectively. 10 patients (2 participated in the TTP) had incomplete data and were excluded from further analysis. Results: Quitters had 100% complete response (CR) on initial assessment following XRT. 7/50 (14%) developed relapsed disease with 4 local recurrences (LR) and 3 distant metastases (DM). 6/50 (12%) developed secondary malignancies. By contrast, Smokers had 96.5% CR on initial assessment following XRT. 8/29 (27.5%) developed relapsed disease with 6 LR and 2 DM. 6/29 (20.6%) developed secondary malignancies. The median follow ups for Quitters and Smokers were 57.5 and 54 months with overall survival rates of 82% and 79%, respectively. Conclusions: Current smokers that achieved smoking cessation prior to XRT demonstrated lower rates of relapse, DM, and secondary malignancies compared to those that continued to smoke. Thus, smoking cessation is an integral part of head and neck cancer treatment and needs to be further incorporated in cancer care to improve cancer treatment outcomes. As a future direction, a comparable group of patients who did not smoke from the same time range will be compared for response rates, LR, DM, secondary malignancies, and survival.

Beyond Cue Reactivity: Non-Drug-Related Motivationally Relevant Stimuli Are Necessary to Understand Reactivity to Drug-Related Cues

Neurobiological models of addiction posit that drug use can alter reward processes in two ways: (1) by increasing the motivational relevance of drugs and drug-related cues and (2) by reducing the motivational relevance of non-drug-related rewards. Here, we discuss the results from a series of neuroimaging studies in which we assessed the extent to which these hypotheses apply to nicotine dependence. In these studies, we recorded smokers’ and nonsmokers’ brain responses to a wide array of motivationally relevant visual stimuli that included pleasant, unpleasant, cigarette-related, and neutral images. Based on these findings, we highlight the flaws of the traditional cue reactivity paradigm and we conclude that responses to non-drug-related motivationally relevant stimuli should be used to appropriately gauge the motivational relevance of cigarette-related cues and to identify smokers attributing higher motivational relevance to drug-related cues than to non-drug-related rewards. Identifying these individuals is clinically relevant as they achieve lower rates of long-term smoking abstinence when attempting to quit. Finally, we show how this approach may be extended beyond nicotine dependence to inform theoretical and clinical research in the study of obesity.

Implications

The cue reactivity paradigm (ie, comparing responses evoked by drug-related cues to those evoked by neutral cues) cannot provide conclusive information about the motivational relevance of drug-related cues. Responses to non-drug-related motivationally relevant stimuli should be used to appropriately gauge the level of motivational relevance that substance-dependent individuals attribute to drug-related cues.

Prequit fMRI responses to pleasant cues and cigarette-related cues predict smoking cessation outcome

INTRODUCTION

The reasons that some smokers find it harder to quit than others are unclear. Understanding how individual differences predict smoking cessation outcomes may allow the development of more successful personalized treatments for nicotine dependence. Theoretical models suggest that drug users might be characterized by increased sensitivity to drug cues and by reduced sensitivity to nondrug-related natural rewards. We hypothesized that baseline differences in brain sensitivity to natural rewards and cigarette-related cues would predict the outcome of a smoking cessation attempt.

METHODS

Using functional magnetic resonance imaging, we recorded prequit brain responses to neutral, emotional (pleasant and unpleasant), and cigarette-related cues from 55 smokers interested in quitting. We then assessed smoking abstinence, mood, and nicotine withdrawal symptoms during the course of a smoking cessation attempt.

RESULTS

Using cluster analysis, we identified 2 groups of smokers who differed in their baseline responses to pleasant cues and cigarette-related cues in the posterior visual association areas, the dorsal striatum, and the medial and dorsolateral prefrontal cortex. Smokers who showed lower prequit levels of brain reactivity to pleasant stimuli than to cigarette-related cues were less likely to be abstinent 6 months after their quit attempt, and they had higher levels of negative affect during the course of the quit attempt.

CONCLUSIONS

Smokers with blunted brain responses to pleasant stimuli, relative to cigarette-related stimuli, had more difficulty quitting smoking. For these individuals, the lack of alternative forms of reinforcement when nicotine deprived might be an important factor underlying relapse. Normalizing these pathological neuroadaptations may help them achieve abstinence.

A randomized double-blind pilot trial of gabapentin versus placebo to treat alcohol dependence and comorbid insomnia

BACKGROUND

Insomnia and other sleep disturbances are common, persistent, and associated with relapse in alcohol-dependent patients. The purpose of this pilot study was to compare gabapentin versus placebo for the treatment of insomnia and prevention of relapse in alcohol-dependent patients.

METHODS

Twenty-one subjects, including 10 women who met study criteria for alcohol dependence and insomnia and expressed a desire to abstain from alcohol, were recruited to the study. During a 1 to 2 week placebo lead-in and screening phase, a complete medical history, physical exam, blood tests, urine drug test, and structured interviews were performed to determine eligibility and patterns of alcohol use and sleep. Insomnia due to intoxication or acute withdrawal, psychiatric or medical illness, medications, and other sleep disorders were ruled out. Subjects were then randomized to either placebo (n = 11) or gabapentin (n = 10) for 6 weeks and titrated over a 10-day period to 1,500 mg or 5 pills at bedtime. After a 4-day taper, subjects were reassessed 6 weeks after ending treatment.

RESULTS

Gabapentin significantly delayed the onset to heavy drinking, an effect which persisted for 6 weeks after treatment ended. Insomnia improved in both treatment groups during the medication phase, but gabapentin had no differential effects on sleep as measured by either subjective report or polysomnography.

CONCLUSION

Because gabapentin is a short-acting medication that was taken only at nighttime in this study, it may possibly exert a nocturnal effect that prevents relapse to heavy drinking by a physiological mechanism not measured in this pilot study.