DISCUSSION
Smoking is a significant risk factor for BC. It is a rich source for
aromatic amines and nitroso compounds which have carcinogenic effect on
bladder by damaging the DNA.7 In a meta-analysis, the
relative risk of BC was found to be 3.47(95% confidence interval
[CI] 3.07–3.91) for current smokers compared to non-smokers. Even
the relative risk of BC for ex-smokers was 2.04 (95% confidence
interval [CI] 1.85-2.25) compared to non-smokers.4The rate of patients who never smoked was 12.7% and the rate of still
smokers were 41.6% in our study population. This data was not
surprising that nearly 90% of our patients were still smokers or former
smokers at the time of diagnosis.
The relation of smoking and the BC is a well-known phenomenon for the
clinicians; on the other hand, patients learn this reality as soon as
they are diagnosed as BC. At this situation all of the BC patients are
advised to give up smoking. The main question is “do the patients
really understand the importance of cessation of smoking and do they
really give up smoking?” Nearly 40% of our study population was
current smoker at the time of diagnosis. Two third of these patients
were still smokers with a mean follow-up time of 37 months. All of the
patients informed about the importance of cessation of smoking for their
both general health and BC several times, but it was surprising that
most of the patients did not understand this reality. Although the
post-diagnosis smoking frequency decreased significantly compared to
pre-diagnosis smoking frequency, the current smokers were still smoking
11 cigarettes per day. Similar results were also seen at Sfakianos et al
study. In their 623 patient series, 138 patients were smoker at the time
of diagnosis. The authors showed that 70% of patients were still smoker
in a median follow-up of 80 months.13 This data
documented that only informing the patients to stop smoking is not
enough to achieve the goal. Professional support and close follow-up
might be necessary.
According to our knowledge this is the first study evaluating the
postoperative time that the BC patients stopped smoking and the reason
of this behavior. Nearly two thirds of the smoking quitters stopped
smoking at the first month of their diagnosis. After this period, the
rate of cessation of smoking decreased significantly. This behavior
might be related with the immediate anxiety of the patients as they
realized their disease. After a period of time, patients might get use
to their disease and lose their apprehension to stop smoking. Nearly all
the patients who gave up smoking after the diagnosis of BC declared that
the reason was the diagnosis of BC. According to our study, the initial
months of the BC diagnosis was very important for the patients to give
up smoking and for the clinicians to achieve their goal. As the time
passed, the probability of patients to stop smoking also decreased. For
that reason, a professional work-up might be necessary as soon as the
diagnosis was made. By this way, clinicians may increase their chance to
ensure their patients to give up smoking.
The effect of smoking on disease recurrence and progression is
debatable. Simonis et al stated that smoking status increased the risk
of BC recurrence and progression. The authors concluded that heavy
long-term smokers and patients who did not quit smoking were at risk for
both recurrence and progression.14 On the other hand,
Sfakianos et al reported that smoking status was not associated with BCG
response, disease recurrence and disease
progression.13 In another study, Kim et al also
reported that smoking status was not a significant factor for BC
recurrence.15 Similar to these findings, van Osch et
al reported that although the smoking cessation indicated a protective
association with BC recurrence, the statistical analysis was not
significant and the authors concluded that this relation could not be
considered as strong.16-17 We also observed that
cessation of smoking was not related with BC recurrence and progression.
The rate of recurrence and progression was similar at patients who
stopped smoking after the diagnosis compared to still smokers.
Smoking status is also important for patients with
MIBC.18 Rink et al revealed that smoking status was
associated with disease recurrence and cancer specific mortality at
radical cystectomized patients.19 Cacciamani et al
stated that smoking was associated with lower neoadjuvan chemotherapy
response before radical cystectomy. In addition, they also revealed
smoking was related with higher recurrence and disease specific
mortality rates at radical cystectomy patients.20 As
the authors showed it, stopping smoking was very important for patients
with MIBC. We were expecting to find high rates of cessation of smoking
in MIBC patients because these patients had to deal with major treatment
protocols, which changed their life significantly. And the major
responsible for this situation was smoking. Surprisingly the rate
cessation of smoking among these patients was only 27.3 %. This data
documented that patients with MIBC insisted to smoke and the clinicians
was not successful in terms of making their patients smoke-free.
However, we predicted the smoking cessation rates would be higher.
Because the patients follow up were more frequent so they had exposed
much more suggestion about smoking cessation from our medical team. In
addition, radical cystectomy is not a simple operation; it is the major
oncological surgery. Therefore, the rates of cessation of smoking were
far below our expectations and consequently the radical cystectomy
patients should be much more encouraged for smoking cessation.
Our study had some limitations. The mean follow-up period of our study
population was 37 months, which might be a short period of time. On the
other hand, the main aim of this study to evaluate the rate and the time
of cessation of smoking in which the follow-up period might be
significant. The status of smoking was documented by self-reported
questionnaire, which may be another limitation of the study. In order to
overcome this possible personal bias, we cross-questioned the close
relatives about the smoking habit of the patient. If there was an
inconsistency about the answers patients were re-questioned.