H&O Approximately how many people in the United States are survivors of cancer?
KSB Currently, an estimated 18 to 20 million people in the United States are survivors of cancer. In oncology, the term “survivor” typically refers to a patient from the time of diagnosis throughout the rest of his or her life.
H&O What are some of the common consequences of surviving cancer?
KSB There can be a wide variety of short- and long-term consequences. They differ according to the type of cancer and, importantly, the type(s) of treatments received—particularly, specific chemotherapy drugs and radiation. There can be abnormalities with the function of various organs (eg, heart, lung, kidneys, brain/central nervous system), as well as endocrinologic issues. Treatment-related symptoms, such as pain, fatigue, neuropathies, sleep problems, and cognitive issues (eg, memory loss, difficulty with concentration), can persist after completion of therapy or arise anew. Unfortunately, patients exposed to chemotherapy and/or radiation are at an increased risk for developing a new cancer (different from their original cancer).
Importantly, patients can also develop significant psychosocial issues, such as depression, anxiety, post-traumatic stress disorder, financial strain, problems with relationships, and difficulties at school or work.
H&O Are there any other important challenges faced by cancer survivors?
KSB It can be difficult for cancer survivors to find health care providers who understand the risks for many of the complications noted above. Clinicians must ensure that survivors undergo appropriate screening for these late effects and receive treatment for any concerns identified.
H&O Do survivors of leukemia or lymphoma raise particular concerns based on their treatments or disease course?
KSB All of the issues noted above can be concerns for these survivors. An issue that is specific to survivors of leukemia or lymphoma is that the treatment for these malignancies can increase the risk of cardiovascular disease, impacting heart function or leading to lipid abnormalities (eg, high cholesterol, high triglycerides). Treatment can also increase the risk for diabetes and other vascular diseases, such as stroke, heart attacks, and hypertension. All of these risks must be monitored in survivors of leukemia or lymphoma.
H&O What are the components of survivorship care?
KSB Survivorship care aims to prevent late effects of the cancer or treatment. It is necessary to educate patients, as well as their primary care providers, regarding late effects. The plan should include a screening schedule for possible complications. It should also include directives regarding the coordination of care, which may involve multiple subspecialists. Survivors should know their risks. They must receive appropriate screening and monitoring for potential complications. Another major component of survivorship care is ensuring that the survivors’ emotional health needs are met.
H&O Is survivorship care typically administered by the original management team, a primary care physician, or specialists in this field?
KSB Any of these clinicians can provide survivorship care. However, it works best if there is a primary care physician to coordinate care among the various providers.
H&O What steps can hematologists/oncologists take near the end of treatment to ensure that their patients receive optimal survivorship care?
KSB Hematologists/oncologists should provide survivors with a treatment summary and survivorship care plan that details all therapies throughout the management course (Table). In some cases, the plan is created by a survivorship clinic. The plan should also include information about the disease, the management course, complications that developed during or after treatment, and any long-term implications. The plan should include potential risks of treatment, including secondary malignancies or specific organ toxicity, with recommendations for screening and follow-up. Copies of the survivorship care plan should be sent to the survivor and his or her health care providers.
Implementation of a survivorship care plan is difficult, and there are currently no good solutions to this issue. It takes a significant amount of time to prepare a treatment summary and survivorship care plan. Current electronic medical record systems do not do a good job of compiling the necessary information. We also do not know the best time to deliver these plans to patients. It can be overwhelming to do so at the end of primary therapy, but the provider should not wait too long afterward.
H&O Are there any studies of the implementation of survivorship care plans?
KSB Many studies have looked at this area, with mixed results. Survivors tend to have very favorable opinions regarding receipt of care plans. However, the plans have not been specifically shown to improve screening for late effects. My colleagues and I studied the impact of care plans among patients who underwent hematopoietic cell transplant. The plans significantly reduced levels of distress, but they did not improve patients’ overall level of health care knowledge. The care plans provided some benefit to patients, but it is necessary to find ways to reinforce the content to strengthen the effect and to change behaviors.
H&O Are there any general recommendations that you provide to patients who have survived cancer?
KSB I tell patients that it is important to maintain a healthy lifestyle, by meeting exercise guidelines, maintaining a healthy body weight, and following a nutritious diet. I recommend that patients undergo a complete physical examination annually. It is especially important to highlight the importance of an annual examination to young adults, who typically skip them. Patients should not ignore new or unusual symptoms; they should visit a doctor for assessment. Patients should educate themselves regarding their risks based on their disease, as well as the treatments they received.
Disclosure
Dr Baker has no real or apparent conflicts of interest to report.
Suggested Readings
Baker KS, Chow EJ, Goodman PJ, et al. Impact of treatment exposures on cardiovascular risk and insulin resistance in childhood cancer survivors. Cancer Epidemiol Biomarkers Prev. 2013;22(11):1954-1963.
Baker KS, Syrjala KL. Long-term complications in adolescent and young adult leukemia survivors. Hematology Am Soc Hematol Educ Program. 2018;2018(1):146-153.
Dengel DR, Kelly AS, Zhang L, et al. Vascular structure and function in cancer survivors after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2019;25(1):151-156.
Denlinger CS, Ligibel JA, Are M, et al. Survivorship: screening for cancer and treatment effects, version 2.2014. J Natl Compr Canc Netw. 2014;12(11):1526-1531.
Ketterl TG, Syrjala KL, Casillas J, et al. Lasting effects of cancer and its treatment on employment and finances in adolescent and young adult cancer survivors. Cancer. 2019;125(11):1908-1917.
Majhail NS, Murphy E, Laud P, et al. Randomized controlled trial of individualized treatment summary and survivorship care plans for hematopoietic cell transplantation survivors. Haematologica. 2019;104(5):1084-1092.
Palmer SC, Stricker CT, Panzer SL, et al. Outcomes and satisfaction after delivery of a breast cancer survivorship care plan: results of a multicenter trial. J Oncol Pract. 2015;11(2):e222-e229.