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Survivorship Care: One Size Does Not Fit All

TON - December 2020, Vol 13, No 6 - Best Practices
Phoebe Starr

Survivorship care encompasses the entire cancer trajectory—from diagnosis to treatment to survivorship. Given the growing number of cancer survivors in the United States, there is a need for increased focus on this aspect of care.

“Survivors represent a growing population we need to attend to in our clinics and in society,” said Ann H. Partridge, MD, MPH, Director, Adult Survivorship Program, Dana-Farber Cancer Institute, and Professor of Medicine, Harvard Medical School, Boston, MA, speaking at the virtual Scripps MD Anderson Cancer Center’s 2020 Cancer Care Symposium. Survivorship programs span all ages and all types of cancers. At least 75% of survivors are aged ≥60 years. “Different groups of patients need different programs, because one size does not fit all,” she emphasized.

“Survivorship care matters because follow-up can detect problems that can be prevented, cured, or controlled. Overuse and underuse of medical resources for follow-up appear common in long-term survivors. We need to extend the evidence base to show what kinds of interventions work,” she added.

Four Buckets of Follow-Up Care

To simplify a very complex issue, Dr Partridge listed 4 “buckets” that are important for follow-up care of patients with cancer: recurrence and new cancers; long-term and life effects (including psychosocial effects); modifiable health behaviors; and coordination of care.

Recurrence and New Cancers

“The issue of surveillance, screening, and prevention of new cancers is most pressing for survivors. We are good at this, especially early on. The question is whether you continue to look for signs of early recurrence in an asymptomatic patient. Testing and early intervention has to make sense for that individual patient,” she said.

For example, evidence from a large study of colon cancer survivors shows that follow-up with either carcinoembryonic antigen scan or computerized tomography scan increases detection of recurrences that could be treated with curative intent. However, when both modalities were used, there was no extra benefit. This evidence is incorporated into the American Society of Clinical Oncology Guidelines for Colon Cancer.

In contrast, randomized clinical trial data do not support routine screening for cancer outside the breast. Overall survival and quality of life are the same for patients randomized to intensive scanning and standard scanning.

“Picking up recurrences very early does not appear to benefit the breast cancer survivor unless there are symptoms,” Dr Partridge said.

She noted that several different guidelines for lung cancer survivors reflect lack of consensus.

“The prudent oncologist follows [the National Comprehensive Cancer Network] guidelines for follow-up,” she said.

Other considerations for this first bucket include genetics, family history, and revisiting genetics at some point after the disease evolves.

Long-Term and Life Effects

The prevention and management of long-term effects is a critical aspect of survivorship care. Depending on the treatment used and the type of cancer, survivors may need referrals to specialists who deal with lung damage, functional and cosmetic effects, heart disease, and secondary cancers.

“We need to have our antennae up when a patient has a complaint or symptom to remember what treatment they had,” Dr Partridge cautioned. “These [treatment-related] effects often occur early on, but sometimes occur later.”

When a patient has a complaint, such as fatigue on androgen-deprivation therapy (ADT), she advised a systems-level approach. ADT has a host of side effects, including cognitive decline, altered body composition, bone thinning, metabolic syndrome, fatigue, and cardiovascular morbidity. Perhaps the patient needs to be referred to a cardiologist, especially if there is a history of cardiovascular disease. Fatigue can be managed by exercise.

In addition to ADT, certain cancer treatments place patients at greater risk for cardiovascular disease, including radiation therapy, anthracyclines, and trastuzumab. Some studies suggest that angiotensin-converting enzyme inhibitors may be helpful in preventing cardiovascular disease in cancer survivors at risk.

“Sexual dysfunction is the elephant in the room. We don’t want to address it and often the patient doesn’t want to either, but you have to ask about sexual function,” Dr Partridge said.

There are therapeutic approaches that can help improve sexuality in both men and women. Perhaps the patient will need a referral to a urologist or a sex therapist.

Fertility preservation is another important area to discuss with younger patients, and there are technologies available to help foster successful pregnancy.

“Survivors often experience a roller coaster of emotions that we need to attend to. These can include depression, fatigue, and cognitive dysfunction. These are 3 sides of the same coin that overlap, and we need to tease out which to treat,” she said. Patients with these problems should be referred to specialists.

Modifiable Health Behaviors

Oncologists also need to address modifiable risk factors, including diet and exercise, smoking cessation, alcohol intake, high-risk sexual behavior, and illicit drug use.

The American Cancer Society’s recommendations for survivorship care “put it all together,” Dr Partridge said. She encouraged nurses and advanced practice providers to review these guidelines and share them with their patients.

Coordination of Care

Coordination of survivorship care relies on treatment summaries and survivorship care plans. There are new tools, apps, and patient safety portals that enable communication with providers.

“Some people might fall through the cracks if they don’t have a road map. It won’t help all patients, but will help some,” Dr Partridge said.

She added that many cancer centers have shifted their focus from treatment summaries to survivorship care plans that focus on addressing needs through direct care and consultative services.

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Last modified: July 22, 2021