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Strategies for caring for the well cancer survivor

The Journal of Family Practice. 2018 October;67(10):624-628,630-635
October 1, 2018|Family Medicine
Michael J. Arnold, MD, CDR, USN;Courtney Saint, DO, LT, USN;Andrea Ochab, DO, LT, USN
Author and Disclosure Information

Uniformed Services University of the Health Sciences, Bethesda, MD (Dr. Arnold); Naval Branch Health Clinic, Atsugi, Japan (Dr. Saint); USS Abraham Lincoln (CVN-72) (Dr. Ochab)
michael.arnold@usuhs.edu

The authors reported no potential conflict of interest relevant to this article.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, or the United States government.

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.

There are few studies of pharmacotherapy of anxiety or depression in cancer survivors56; it is known that cancer survivors are nearly twice as likely as the general population to be taking medical therapy for anxiety and depression.58 A Cochrane systematic review of 7 small studies showed uncertain improvement in depressive symptoms in patients with cancer from antidepressant medication; however, an earlier systematic review did show benefit.59,60

Second malignancies are dangerous; 55% of patients die of the second cancer, compared to only 13% of their initial cancer.

In a trial of patients without depression who were being treated for head and neck cancer, escitalopram, 20 mg/d, reduced the risk of subsequent depression compared with placebo.61 A study of 420 breast cancer survivors showed that 300 mg/d and 900 mg/d dosages of gabapentin were both superior to placebo, and nearly equivalent to each other, at reducing anxiety scores.62 In both studies, however, the evidence is nonetheless insufficient to make specific recommendations about these medications.

Cardiac risk. The risk of cardiovascular morbidity in cancer survivors is, in fact, higher than the risk of recurrence of cancer.63 Cancer survivors have 5 times the risk of heart failure and 10 times the risk of coronary artery disease and cerebrovascular disease than patients without cancer.63 Most of this risk is incurred because of the physiologic effects of chemotherapy and radiation.

Among chemotherapeutic agents, anthracyclines, such as doxorubicin, cause the most rapid and striking myocyte damage. This damage is dose-dependent and nearly irreversible, with 98% of injury occurring within the first year of chemotherapy.64 More than one half of cancer patients taking an anthracycline have cardiac dysfunction on imaging; 5% will be in overt heart failure 10 to 20 years, or longer, after chemotherapy.63 Following monitoring at 1 year post-therapy, regular cardiac imaging is not recommended in the absence of symptoms.62

Because other cardiotoxic chemotherapeutic agents cause partially reversible damage, imaging is not recommended in the absence of symptoms in patients taking those agents.64

Continue to: Radiation therapy to the chest leads...

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