Study suggests greater awareness is needed on impact of smoking for patients with bladder cancer

Richard S. Matulewicz, MD, MSCI, MS, discusses the findings from his recent study that looked at patient knowledge about the link between smoking and bladder cancer.

Findings of a recent study show that there is a gap in patients’ knowledge about the association between bladder cancer and smoking.1 Richard S. Matulewicz, MD, MSCI, MS, and colleagues reported that about 25% of patients with bladder cancer who were continuing to smoke following their diagnosis were not aware of the link between bladder cancer and smoking. Matulewicz discusses these results further in the following interview conducted by Urology Times®, where he emphasizes the need for urologists to take a more active role in patient education.

Please describe the background for this study.

This study was a secondary analysis of another study that was previously published that was led by Dr. Helena Furberg [PhD, MSPH], here at Memorial Sloan Kettering (MSK). It was called the DETER study. This was a study that was undertaken to better understand the way patients' smoking status and continued smoking has an effect on their recurrences and progression in non–muscle-invasive bladder cancer. So along with a wealth of biospecimen and other cancer outcomes data, the study investigators here at MSK also included surveys of patient knowledge, behaviors, and perceptions. These patient-reported outcomes were collected systematically as part of the study.

What we wanted to do was begin to unpack why patients continued to smoke after diagnosis and maybe some of the reasons for all of those behaviors. A lot is still unknown about how patients' knowledge of risk factors and patients' knowledge of continued smoking are involved in their behaviors and the way that they approach their post-cancer diagnosis lifestyle changes. We used this study as a first step in understanding at a baseline what patients with non–muscle-invasive bladder cancer thought and what they believe to be risk factors for their bladder cancer. The 4 most common ones, and the ones that we explored, are age, family history, and then exposure to either cigarette smoking and tobacco or chemicals. So those were the 4 that we asked about in our survey.

What were some of the notable findings? Were any of those surprising to you and your coauthors?

The study itself included about 540 patients, which is a large cohort of patients with non–muscle-invasive bladder cancer. The demographics of the study reflect a contemporary non–muscle-invasive bladder cancer population; it was predominantly men and the median age was about 68 years old. About 10% of the cohort were current smokers, and about 54% of the cohort were former smokers, so about two thirds in total had some prior exposure to cigarette smoking and tobacco use. At the higher level when looking at the entire cohort, only about half of patients really believe that age and family history were potential causes of bladder cancer. About 78% to 79% believe that cigarette smoking and chemical exposures were causes of bladder cancer.

Among these different proportions, there was an interesting finding that patients who were former smokers were more likely to report that smoking is a risk factor for bladder cancer, compared to both never smokers and current smokers. Looking at the group of people who were continuing to smoke after their diagnosis, about 1 in 4 of these patients were not aware that smoking was a risk factor for the bladder cancer that they have, while they continue to smoke. That is really the most important finding and the biggest gap that we were able to identify that we hope can be leveraged for patient education and to help patients understand the benefits of quitting smoking.

Is any further research on this topic planned? If so, what will that focus on?

There's a lot more to be done here, and certainly a lot more that we need to explore. Although we had a large cohort, about 500 patients, with only 10% being current smokers, there's a lot that we weren’t unable to understand statistically as to why some of our findings were found. When looking at how certain patient characteristics play into patient knowledge, why were former smokers more knowledgeable that smoking was a risk factor for bladder cancer? Is that why they're former smokers? Is that why they quit? Is it something unique about their treatment or their counseling throughout their treatment pathway that gave them that knowledge? Was it a specific doctor or other health professional that helped them understand that then promoted their smoking cessation? Or are these patients that had quit smoking a very long time ago because they were worried about bladder cancer, and now that they're dealing with this, they're much more aware?

One of the other questions is what is the best way to educate patients? We have a group of patients where 25% have been diagnosed with bladder cancer and have presumably been seen by multiple different doctors and multiple different institutions. [Memorial Sloan Kettering Cancer Center is] a tertiary referral center, so a lot of patients are not early on in their cancer journey when they get to us. So why aren't these patients aware that their continued smoking could actually be really negatively affecting not only their overall health, but certainly their bladder cancer treatment outcomes?

So there's certainly a lot to be done here still. This is work we are actively doing not only with this study in particular, but really at the at the grander scale, where we're trying to figure out the best way to get patients evidence-based smoking cessation treatments in urologic cancers, and also in all of the surgical oncology settings here at MSK.

What is the take-home message for practicing urologists?

The most important thing here is that we really need to spend time on education and counseling for our patients. We cannot just simply be technicians that deal with a tumor and cut the tumor out and don't really approach the underlying issue. Cigarette smoking and continued smoking exposes patients to a lot of continued risk, and I don't think we're doing our job as a doctor by ignoring this critical part of counseling and education. We know from other studies that patients who are better informed about the risks of continued smoking more often quit. We know that there are not only benefits for bladder cancer, but also for patients' general health. One of the most impactful few minutes we can spend with a patient when we're seeing them for bladder cancer is helping them understand how to promote some of the behavior changes and lifestyle modifications that will get to the root of the problem and improve their general health.

Is there anything else that you would like to add?

Some of my colleagues and I have been beating this drum for a few years now. I do think that there's good progress being made as far as awareness goes, but having urologists assume the role of leaders in tobacco treatment and smoking cessation is very necessary. That goes beyond just individual efforts. The awareness of tobacco as a risk factor for not only bladder cancer, but also a number of different urologic disease processes, is critically important. Including standardized systematic assessment of tobacco use and treatment in our guideline statements, in some of our clinical practice guidelines, developing quality metrics—certainly for the cancers and the disease processes that are directly linked to tobacco use—will be a way of a rising tide raising all ships.

[We need to be] improving trainee and continuing medical education in this, where we don't necessarily need to be writing prescriptions, but we need to at least be aware of the importance of this. [We can urge] some of our colleagues who may be physicians, may be other allied health professionals, to use their expertise and their experience to get patients evidence-based pharmacotherapies and also behavioral counseling. I would say that the simplest way of going about this is being aware of the 1-800-QUIT-NOW hotline. This is something that takes 2 seconds to let patients know about, and patients calling that hotline, it’ll link them up to a counselor, it'll get them pharmacotherapy mailed to their house, and it will get them local treatment because this is run by each state. I think taking notice of this as an important part of what we do every day is the most critical part of it.


1. Matulewicz RS, Whiting K, Bochner BH, et al. Knowledge of bladder cancer risk factors among patients diagnosed with nonmuscle-invasive bladder cancer. J Urol. Published online October 4, 2022.