Transcranial Magnetic Stimulation (TMS) for Smoking Cessation in Cancer Survivors: A Path Forward

Cigarette smoking after a cancer diagnosis is associated with increased mortality, cancer recurrence, treatment-related toxicity, and diminished quality of life, yet sustained cessation remains a challenge. Transcranial magnetic stimulation (TMS), an FDA-approved noninvasive neuromodulation treatment for both major depressive disorder and smoking cessation, represents a promising intervention for cancer survivors due to its unique multitarget effects. Cancer survivors experience high rates of comorbid psychopathology, including depression, anxiety, suicidal ideation, and pain-conditions that interact with smoking behaviors and for which TMS has demonstrated efficacy. However, the current standardized TMS protocol for smoking cessation requires adaptation for cancer populations, given their unique clinical needs. This paper proposes a stakeholder-engaged adaptation framework involving cancer survivors, oncology clinicians, tobacco treatment specialists, TMS psychiatrists, and other key stakeholders to systematically adapt TMS protocols for cancer survivors. We discuss a roadmap for procedural adaptation prior to efficacy trials, including flexible dosing schedules and accelerated protocols, secondary outcome measures beyond smoking behaviors, implementation considerations for integration into oncology care settings, and anticipated barriers and potential solutions. This framework provides a roadmap for developing an optimized, equitable TMS intervention to improve smoking cessation outcomes in cancer survivors.