Applied Evidence

Strategies for caring for the well cancer survivor

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.


 

References

Cancer survivors represent a rapidly increasing population. In 1971, there were 3 million cancer survivors; this number increased to 15.5 million in 2016 and will reach 20 million by 2026.1TABLE 11 shows the percentage of survivors by type of cancer. Cancer survivors tend to be older,* comprising nearly 1 of every 5 people older than 65 years.2

Estimated prevalence of cancer survivors by type

The Institute of Medicine (IOM) identified 3 key characteristics of cancer survivors3:

  • Trajectories of survivorship are variable; many cancer patients have periods of relative health between episodes of their disease.
  • Survivors require careful cancer monitoring; in addition to the risk that their primary cancer will recur, they have an elevated risk for another, second cancer.
  • Both cancer and its treatments increase the risk of other medical and psychiatric problems.

Family physicians (FPs) have optimal skills for navigating the chronic risks and health concerns of the well cancer survivor. This article reviews the primary care management of the functional cancer survivor, focusing on the management of chronic conditions and preventive care.

Survivorship follows any of 6 paths

Cancer survivorship is increasing in importance as treatment has steadily reduced mortality. Six trajectories of cancer survivors have been identified1:

  • living cancer-free after treatment with minimal effects
  • living cancer-free but suffering serious treatment complications
  • Suffering late recurrence
  • Developing a second cancer
  • Living with intermittent cancer recurrences
  • Living with cancer continuously.

Only patients in the last 2 groups are likely to be managed primarily by oncologists.

Survivors look to their FPs for ongoing care

Cancer survivors routinely see their primary care physician after initial treatment. A study of 30,000 Canadian breast cancer survivors demonstrated that follow-up care was limited to an oncologist in only 2%; 84% saw a primary care provider and an oncologist; and 14% saw a primary care provider only.4 A study of colorectal cancer survivors showed that primary care visits increased in each of the 5 years after diagnosis, during which time oncology visits decreased steadily5; in that study, primary care physicians delivered more preventive care than oncologists did.5 Similar to what is done in other chronic conditions, the various effects of cancer are best managed as a whole.

The IOM recommends that cancer survivor care comprise 4 elements2:

  1. coordination between oncologist and primary care physician
  2. surveillance for recurrence or spread of existing cancer
  3. screening for new cancer
  4. intervention for the effects of cancer and treatment.

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