Strategies for caring for the well cancer survivor
Surveillance of existing cancer, management of treatment-related adverse effects, and screening for second cancers are key to the care you'll provide.
PRACTICE RECOMMENDATIONS
› Provide normal age-related cancer screening for cancer survivors because of their high risk of a second cancer. B
› Strongly encourage lifestyle changes for cancer survivors, especially smoking cessation. B
› Recommend exercise, which alleviates pain, depression, anxiety, and (more effectively than any other intervention) fatigue, for cancer survivors. B
› Remain vigilant for the development in cancer survivors of cardiovascular disease, including heart failure, which can appear long after therapy. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
*Cancer survivor care in the pediatric patients, including application of a survivorship care plan (also discussed later in this article), is reviewed in “Partnering to optimize care of childhood cancer survivors,” The Journal of Family Practice, April 2017.
Yet adherence to cancer surveillance recommendations is poor. A study of patients with colon cancer demonstrated that only 12% met all recommended surveillance guidelines.16 A study of patients with bladder cancer after radical cystectomy showed that only 9% met recommended surveillance more than 2 years after diagnosis.17 Those dismal statistics may be the result of provider oversight—not patient reluctance.
In the colon cancer study, for example, compliance with follow-up colonoscopy was 80% but compliance with carcinoembryonic antigen testing was only 22%.16 In the bladder cancer study, follow-up urine cytology was obtained in only 23% of patients, although 75% completed recommended imaging.17
Although surveillance remains the oncologist’s responsibility, visits to the FP provide an opportunity to review surveillance and order needed laboratory testing and other studies, including imaging.
3. Screen for new cancers
The risk of a second cancer is elevated for cancer survivors compared with the risk of a primary cancer in the healthy general population; some survivors have a lifetime risk of a second cancer as high as 36%.18 Risk varies by cancer type (TABLE 319). Some of this variation is due to the impact of smoking: Smoking-related cancers have the highest risk of second malignancy.19 Genetic predisposition to malignant transformation is also theorized to contribute to increased risk. Second malignancies are dangerous; 55% of patients die of the second cancer compared with only 13% of their initial cancer.19
Studies show that cancer survivors display varying adherence with recommended screening for second cancers. In a study of Latina cancer survivors, depressive symptoms were associated with lower screening compliance.20 A study of survivors of hematologic cancer showed a low rate of cancer screening and high fear of cancer recurrence—suggesting avoidance due to fear.21 Other studies, however, show similar or increased compliance with screening in cancer survivors.22,23 A meta-analysis of 19 studies determined that, overall, cancer survivors receive 25% to 38% more recommended screening than the general population.24
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