You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.
 

CME / ABIM MOC / CE

Do Smoking and Alcohol Increase Risk for Second Squamous Cell Carcinoma?

  • Authors: News Author: Heidi Splete; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 2/11/2022
  • Valid for credit through: 2/11/2023
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for medical oncologists, dermatologists, gastroenterologists, internists, nurses, pharmacists, and other members of the health care team for patients with squamous cell carcinoma of the esophagus, head, and neck.

The goal of this activity is to describe the effect of alcohol intake and abstinence on acetaldehyde-induced DNA damage on the esophageal epithelium in individuals with aldehyde dehydrogenase 2 dysfunction, using a mouse model; the effect of direct acetaldehyde exposure on esophageal epithelial cells on inducing gene mutations; the effect of various risk factors on developing multiple dysplastic epithelium in the esophagus of patients with squamous cell carcinoma of the esophagus compared with cancer-free healthy subjects; and the effect of long-term alcohol and cigarette cessation on field cancerization, based on a Japanese cohort study and mouse model.

Upon completion of this activity, participants will:

  • Assess risk factors for developing multiple dysplastic epithelium in the esophagus of patients with squamous cell carcinoma of the esophagus compared with cancer-free healthy subjects and the effect of long-term cessation of alcohol and cigarette use on field cancerization, based on a Japanese cohort study
  • Evaluate the clinical implications of risk factors on development of multiple dysplastic epithelium in the esophagus of patients with squamous cell carcinoma of the esophagus compared with cancer-free healthy subjects and the effect of long-term cessation of alcohol and cigarette use on field cancerization, based on a Japanese cohort study
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Heidi Splete

    Freelance writer, Medscape

    Disclosures

    Disclosure: Heidi Splete has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Own stock, stock options, or bonds from the following ineligible company(ies): AbbVie (former)

Editor/CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape, LLC designates this continuing education activity for 0.25 contact hour(s) ( 0.025 CEUs) (Universal Activity Number: JA0007105-0000-22-017-H01-P).

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME / ABIM MOC / CE

Do Smoking and Alcohol Increase Risk for Second Squamous Cell Carcinoma?

Authors: News Author: Heidi Splete; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/11/2022

Valid for credit through: 2/11/2023

processing....

Clinical Context

Alcohol and cigarette use are established risk factors for various cancers and act synergistically to increase esophageal squamous cell carcinoma (ESCC) and head/neck SCC risk. Field cancerization impairs patients' quality of life and survival, increasing risk for multiple cancers even after curative treatment. Alcohol and smoking cessation has an unknown effect on field cancerization risk.

Study Synopsis and Perspective

Field cancerization and subsequent second cancer in patients with SCC were significantly associated with cigarette and alcohol use, based on data from more than 300 individuals.

Cigarette and alcohol use are established risk factors for SCCs of the esophagus, head, and neck, Manabu Moto, MD, from Kyoto University, Japan, and colleagues write. "In addition, squamous cell carcinoma...and squamous dysplastic epithelium develop multifocally in these organs," in a phenomenon known as field cancerization, but the interaction of multiple dysplastic epithelium with other factors--notably, whether cessation of cigarette and alcohol use would reduce risk for SCC--has not been well studied.

In a study published in Gastro Hep Advances, the researchers identified 331 adults with newly diagnosed superficial esophageal SCC who underwent endoscopic resection and 1,022 healthy control participants. Field cancerization was based on the number of Lugol-voiding lesions (LVLs) per endoscopic view according to 3 groups: grade A, 0 LVLs; grade B, 1-9 LVLs; or grade C, at least 10 LVLs. The primary study outcome was a measure of risk factors for the development of LVLs.

"Multiple LVLs are closely associated with inactive aldehyde dehydrogenase 2 (ALDH2) and field cancerization," the researchers note. Before assessing their human subjects, they used a mouse model to investigate whether alcohol intake and abstinence would affect acetaldehyde-induced DNA damage to the esophageal epithelium among individuals with ALDH2 dysfunction.

The researchers found that DNA damage, measured by acetaldehyde-derived DNA adduct levels (via N2-ethylidene-dG), accumulated with alcohol consumption over time, but decreased with alcohol cessation in the mouse model.

For the human part of the study, participants completed a lifestyle survey at entry, with questions about alcohol consumption history, alcohol flushing response, smoking, consumption of high-temperature foods, and consumption of green and yellow vegetables and fruit. Drinking status was divided into 5 groups: never/rarely (<1 unit/week), light (1-8.9 units/week), moderate (9-17.9 units/week), heavy (18 or more units/week), and ex-drinker, with 1 unit defined as 22 g ethanol. Smoking was divided into 3 groups: never (0 pack-years), light (< 30 pack-years), and heavy (30 or more pack-years). Patients were given educational materials at study entry about the importance of alcohol and smoking cessation, as well as verbal advice to cease these behaviors.

Participants underwent endoscopic surveillance at 3-month intervals for up to 6 months after endoscopic resection.

Overall, increased alcohol consumption was associated with increased risk in development of LVL across all LVL grades; higher grades of LVLs were positively associated with high-intensity alcohol consumption, smoking, flushing, and high-temperature foods, and negatively associated with eating vegetables and fruit.

The risk for LVL grade progression was most strongly associated with increased alcohol consumption and with reported flushing. "The greatest risk was observed in the patients with flushing reactions who consumed an average of 30 units per week in grade C LVL," with an odds ratio of 534, compared with healthy controls, the authors write. "Since flushing reaction is caused by accumulation of acetaldehyde due to ALDH2 [deficiency], our result also means that acetaldehyde is a strong carcinogen in field cancerization."

Secondary outcomes included the incidence of second primary esophageal SCC and head/neck SCC; these were significantly more prevalent in patients with grade C LVL (cumulative 5-year incidence of 47.1% for ESCC and 13.3% for head and neck SCC). However, alcohol and smoking cessation significantly reduced the development of second primary esophageal SCC (adjusted hazard ratios, 0.47 for alcohol and 0.49 for smoking).

The study findings were limited by several factors including the lack of randomization to noncessation and cessation groups and the inclusion of patients with cancer, but not long-term cancer survivors, the researchers noted.

"We believe that our data will be useful to establish a prevention and surveillance strategy for cancer survivors, because the overall prognosis of esophageal cancer and head and neck cancer is still poor," with a 5-year survival rate of less than 20%, and the results highlight the need to educate cancer survivors on the value of smoking and alcohol cessation, they added.

The study was supported by the National Cancer Center Research and Development Fund 36 by the Ministry of Health, Labour, and Welfare of Japan. The researchers have disclosed no relevant financial relationships.

Gastro Hep Advances. Published online October 21, 2021.[1]

Study Highlights

  • This multicenter cohort study included 331 patients with superficial ESCC treated endoscopically, as well as pooled data from 1,022 healthy subjects.
  • Esophageal mucosa physiology was classified into 3 grades based on LVLs per endoscopic view: A (0 LVLs), B (1-9 LVLs), or C (≥10 LVLs).
  • Patients completed a self-administered questionnaire regarding lifestyle, were counseled by physicians to stop alcohol drinking and smoking, and were endoscopically surveyed every 3 months for up to 6 months after endoscopic resection.
  • In a mouse model, DNA damage measured by acetaldehyde-derived DNA adduct levels (via N2-ethylidene-dG) increased over time with alcohol intake, but decreased with alcohol cessation.
  • In humans, the amount of alcohol intake correlated positively with the amount of acetaldehyde-derived DNA adducts.
  • ALDH2 genotype did not affect esophageal DNA adduct level in healthy subjects.
  • LVL grades were positively associated with alcohol drinking intensity, flushing reactions, smoking, and eating high-temperature food, and negatively with eating green/yellow vegetables and fruit.
  • Risk for LVL grade progression was most strongly associated with increased alcohol consumption and with reported flushing.
  • Patients with flushing reactions who consumed an average of 30 units alcohol per week had the greatest risk for grade C LVL (odds ratio, 534 [95% confidence interval, 82.9%<999%] vs healthy controls).
  • The grade C LVL group had significantly higher cumulative 5-year incidences of second primary ESCC (47.1%; 95% CI, 38.0-57.2) and HNSCC (13.3%; 95% CI, 8.1-21.5).
  • Alcohol and smoking cessation were associated with significantly lower risk of developing a second primary ESCC (adjusted hazard ratios, 0.47 [95% CI, 0.26-0.85] and 0.49 [95% CI, 0.26-0.91], respectively).
  • The investigators concluded that alcohol drinking, smoking, flushing reaction, and high-temperature food were strongly associated with inactive ALDH2 and field cancerization and that alcohol and smoking cessation significantly lowered risk of developing second primary cancer.
  • As accumulation of acetaldehyde resulting from ALDH2 deficiency causes flushing reaction, the greatest risk for grade C LVL among heavy drinkers with flushing reactions indicates that acetaldehyde, accumulated by drinking alcohol, is a strong carcinogen in field cancerization.
  • Unlike most previous studies that focused on development of cancer itself, this study was unique in examining development of dysplastic squamous epithelium.
  • These findings should inform a prevention and surveillance strategy for cancer survivors, which is needed given the poor overall prognosis of ESCC and HNSCC, with a 5-year survival rate lower than 20%.
  • The findings highlight the need for clinicians to educate cancer survivors regarding the benefit of smoking and alcohol cessation.
  • In particular, stopping drinking for at least 5 years significantly lowered risk of developing second primary ESCC, especially among patients with grade C LVL.
  • As alcohol and smoking cessation can improve LVL status, this appears to inhibit expansion of squamous dysplastic epithelium and reduce development of second primary cancers.
  • Consumption of green-yellow vegetables and fruit also lowers risk for field cancerization.
  • Study limitations include small number of heavy drinkers, lack of randomization to noncessation and cessation groups, and inclusion of patients with cancer, but not of long-term cancer survivors.

Clinical Implications

  • Alcohol drinking, smoking, flushing reaction, and high-temperature food were strongly associated with inactive ALDH2 and field cancerization.
  • The findings suggest that alcohol and smoking cessation significantly lowered risk of developing second primary cancer among patients with ESCC/HNSCC.
  • Implications for the Health Care Team: The findings highlight the need for clinicians to educate cancer survivors regarding the benefit of smoking and alcohol cessation.

 

Earn Credit

  • Print