The importance of follow-up care after cancer therapy

Dr Ria David details why follow-up care after cancer treatment is of utmost importance.

The term cancer survivor refers to any person who has been diagnosed with cancer. Survivorship encompasses the period from diagnosis, through active treatment, chronic or intermittent disease to cure or end-of-life care. 

In the period following active treatment of a cancer, follow-up and regular monitoring is important to detect several complications:

1. Disease recurrence.
2. Development of short- and long-term physical complications of the previous cancer and its treatment. For example, lymphoedema, cardiovascular disease, chronic fatigue and sexual dysfunction.
3. Detection of other chronic illnesses in an aging population.
4. Surveillance for psychological effects on survivors and caregivers.
5. Screening for subsequent primary cancers.
6. Evaluation of concerns over employment, insurance and disability.
7. Evaluation of genetic risk in cases of concerning family history. 
8. Co-ordination between specialists and primary health providers to ensure that the patient’s needs are met. 

Due to greater awareness of cancer, availability of screening interventions that allow for earlier detection and a myriad of advances in cancer therapy, the number of cancer survivors is expected to increase each year. 

There is therefore a growing need for well-developed survivorship programmes to cater for the unmet needs of this expanding population. 

Risk of recurrence

Following the treatment of the primary cancer, survivors are at risk of recurrence. Monitoring for recurrence often involves clinical assessment (history and examination), evaluation of blood parameters, and selected radiological assessments. For example, annual mammography for breast cancer survivors. 

Risk of second primary cancers

Some treatments for cancer can put patients at risk for other malignancies. The incidence of these second cancers is usually extremely low. Certain cancers, like head and neck malignancies and Hodgkin lymphoma, are associated with a relatively higher risk of second cancers. These may be detected at follow-up appointments. 

Chemotherapy-related leukaemia typically occurs between two to five years following treatment. Radiation-related cancers have a longer latency period and can develop between five to 10 years after this treatment.

Screening for subsequent primary cancers

Childhood survivors of cancer may be eligible for screening mammography and/or breast MRI from age 25 following radiation to the chest. Those who have received abdominal radiotherapy may require screening colonoscopy from age 30 onwards. Some survivors who have had radiotherapy to the chest or axilla may need surveillance for lung cancer with CT scans. 

Monitoring for long -term physical effects of treatment

Late long-term physical effects of treatment may include cardiovascular disease, peripheral neuropathy, hearing loss, lymphoedema, bone loss, premature menopause, erectile dysfunction and chronic infection. Asymptomatic individuals should have at least an annual visit to their doctor for a systematic review to detect some of these problems. 

Psychological well-being

Common long-term psychological disturbances include depression, anxiety, disturbance in sleep cycle, cognitive dysfunction, sexual dysfunction, chronic pain and opioid dependency issues. Providers caring for cancer survivors are advised to ask about these problems at each follow-up visit as patients are often reluctant to admit to them due to fear of stigmatisation. 

Fiscal well-being

Cancer survivorship often results in a significant economic burden, sometimes referred to as financial toxicity, due to the high costs of modern treatment and loss of gainful employment on treatment. Providers can assist by completing insurance forms and referrals to appropriate social institutions to partially compensate for lost income. 

Fertility and parenthood

Cancer therapy may put male and female patients at risk of infertility. Reproductive education and advice on sperm banking, oocyte preservation, adoption and surrogacy may be helpful to some individuals. 

Preventive care

Advice on diet and lifestyle, smoking cessation and limiting of alcohol consumption is important to ensure good long-term general health. 

Communication and co-ordination are critical in good survivorship care. Several guidelines are available for clinicians in specialist- and primary care practice, though there is little data to support much of this advice. Ultimately, good multi-disciplinary care is required to ensure holistic care of all cancer survivors. 

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