Cancer survivorship beyond treatment: a medical viewpoint

Dr Nirasha Chiranjan enlightens us on the impact that cancer and cancer treatment has on cancer survivorship.

A cancer survivor refers to any person who has been diagnosed with cancer. Survivorship begins at the time of diagnosis and includes the periods of initial treatment with intent to cure, cancer-free survival, chronic or intermittent disease, and end-of-life care.¹ 

There are millions of survivors worldwide. This number is expected to grow due to improvements in cancer screening, increases in life expectancy following definitive cancer treatment and the aging of the population. 

For cancer survivors who are no longer on active treatment, healthcare needs include surveillance for recurrence, screening for the development of subsequent primary cancers, monitoring and intervention for the long-term and late physical and psychological effects of cancer and preventive care.

For some survivors, the consequences of cancer are minimal with many returning back to a normal life after treatment. However, many survivors experience physical and psychosocial effects of cancer and its treatment. 

Risk of recurrence

Following treatment of a primary cancer, survivors are at risk for recurrence. Recurrences may occur at the initial site diagnosed (loco regional) or in a different location (metastatic disease). The timing and patterns of recurrence, particularly of distant disease, vary by cancer type and stage at diagnosis. 

Cancer survivors are also at a higher risk for developing a second (or subsequent) primary cancer.² Patients with the highest risk of developing a subsequent primary cancer includes survivors of head and neck cancers and Hodgkin’s lymphoma.

Subsequent primary cancers in cancer survivors occur due to multiple clinical factors, including prior treatment for the primary cancer (chemotherapy, radiation), 

lifestyle habits (smoking, obesity) and genetic factors.³ This data suggests an opportunity for doctors to reduce or prevent the risk of subsequent primary cancers in cancer survivors through lifestyle interventions (cease smoking, alcohol counselling, diet, and physical activity) as well as cancer screening and genetic counselling.

Monitoring for long-term effects of cancer and its treatment

Cancer survivors are at risk for other conditions related to both their disease and its treatment, which are of increasing importance as survival rates improve. 

Late physical effects of treatment include pain, fatigue, depression, lymphoedema, urinary and bowel problems, cardiotoxicity, subsequent malignancy, peripheral neuropathy, hearing loss, infection, loss of bone mass, premature menopause in women and sexual dysfunction.^4,5

Psychosocial well-being

Cancer survivors have been shown to experience a number of difficulties that can impact general quality of life, including depression, anxiety, fatigue, cognitive limitations, sleep problems, sexual dysfunction, pain, and opioid dependence.⁶

A number of interventions for cancer survivors have been evaluated, with both psychosocial and exercise interventions reporting beneficial effects on quality of life.

Employment and fiscal well-being

Cancer and its treatment often have an adverse effect on work status, work performance and job satisfaction. Survivors often take long breaks from work and returning to work is critical in restoring normalcy. Survivors can be left with disabilities or long-term effects that decrease their employment prospects. 

Cancer survivorship results in a significant economic burden years after the diagnosis. With lost earnings and increased expenses, the financial burden is a great one. This can lower quality of life, increase psychological distress and impact adherence to prescribed medications. 

Doctors should inquire about the financial status of patients and whether financial difficulties exist. If issues are identified, patients should be referred to social workers, case managers, and other support services.⁷

Fertility and parenthood

Cancer therapy may put male and female survivors at risk for infertility. Patients may be concerned about their chances of getting pregnant, suffering a miscarriage, and/or achieving a successful pregnancy outcome. 

Furthermore, cancer survivors may be fearful that their history of cancer or its treatment will have an adverse impact on offspring conceived after their cancer treatment, such as placing them at risk for malignancy, congenital anomalies, or impaired growth and development. They may also be concerned about the risks of pregnancy on cancer recurrence. For these patients, education regarding reproductive function is an important aspect of their care.

Preventative care

• Both diet and physical activity can improve the quality of life and can minimise both disease and treatment-related side effects in cancer survivors.
• Stop smoking – cancer survivors are at increased risk for subsequent cancers, and the risks are significantly higher among those who continue to smoke.
• Limit alcohol consumption.
• Genetic evaluation and testing – genetic factors may have important implications for the survivor’s family members.

Survivorship care plan  

Cancer survivorship is often a hard transition to a new normal. A cancer survivorship care plan is often formulated between the patient and treating team. It’s a record of your cancer and treatment history. It may list the follow-up needed, future tests required, possible long-term side effects and preventative strategies. 

Conclusion 

Cancer survivors want health, longevity and quality of life. The road to these outcomes may be riddled with obstacles, involving medical uncertainty, treatment outcomes, social expectations and economic burden. Health practitioners need to become actively involved in survivorship at all levels of care.

References

1. Hewitt M, Greenfield S, Stovall E, et al. From cancer patient to cancer survivor: Lost in transition. National Academies Press, Washington DC, 2006. http://www.iom.edu/Reports/2005/From-Cancer-Patient-to-Cancer-Survivor-Lost-in-Transition.aspx (Accessed on January 31, 2011).
2. Kok JL, Teepen JC, van der Pal HJ, et al. Incidence of and Risk Factors for Histologically Confirmed Solid Benign Tumors Among Long-term Survivors of Childhood Cancer. JAMA Oncol 2019; 5:671.
3. Chao C, Bhatia S, Xu L, et al. Incidence, Risk Factors, and Mortality Associated With Second Malignant Neoplasms Among Survivors of Adolescent and Young Adult Cancer. JAMA Netw Open 2019; 2:e195536.
4. Ganz PA. Survivorship: adult cancer survivors. Prim Care 2009; 36:721.
5. Nekhlyudov L, Aziz NM, Lerro C, Virgo KS. Oncologists’ and primary care physicians’ awareness of late and long-term effects of chemotherapy: implications for care of the growing population of survivors. J Oncol Pract 2014; 10:e29.
6. Harrington CB, Hansen JA, Moskowitz M, et al. It’s not over when it’s over: long-term symptoms in cancer survivors–a systematic review. Int J Psychiatry Med 2010; 40:163.
7. Ramsey S, Blough D, Kirchhoff A, et al. Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood) 2013; 32:1143.

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