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Cancer Supportive and Survivorship Care Improving Quality of Life Logo

Cancer is a life-changing event!
Ernest H. Rosenbaum, MD, Patricia Fobair, LMSW, MPh, and David Spiegel, MD

The Challenge
Ways to Improve Health and Longevity

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The challenge is to control and hopefully cure cancer through newer and better therapies that will prevent or arrest the disease quickly so that survivors can minimize medical and social hazards. A cancer survivor is defined as one living from the time of diagnosis, throughout the remainder of his or her life with and beyond cancer.

Currently, there are over 1 million new cases of cancer diagnosed each year in the United States; by the year 2030 this number is expected to double. The National Cancer Institute (NIH) and American Cancer Society (ACS)currently projects that about 1/3 of women and 1/2 of men will have cancer in their lifetime. One in four people are expected to die from the disease.

At the same time, the survival rate is increasing, rising from 3 million survivors 15 years ago to over 10 million survivors in the year 2006. This rate will continue to increase as diagnosis, treatment and care advance. It is estimated that by 2030 there will be over 20 million survivors. Cancer has become a chronic disease.

Unfortunately, many survivors may experience lasting adverse side effects of treatment. Although the current 5 year survival rate is 64% (compared to 50% 25 years ago), the estimated follow up needed is at least 10-20 plus years, the remainder of the survivor's life. Susan Sontag's cancer experience provides a good example of the potential for productivity, wellness and longevity in survivorship. Diagnosed and treated for metastatic breast cancer at age 45, she subsequently died at age 71 of a new cancer.

Despite advances and innovations in cancer diagnosis and treatment, the consequences for survivors remain serious. Over 50% of cancer survivors have residual side effects; over 25% experience recurrence or develop new cancers. It is estimated that 75% of survivors can have health deficits related to their treatment. 1

There is also overwhelming evidence that cancer patients die of noncancer causes at a higher rate than persons in the general population. 2 Added to known cancer-specific vulnerabilities, the increased risk of additional illnesses (or co-morbid conditions) makes the need for follow-up programs for cancer survivors even more urgent.

Age is a major risk factor which has recently been shown to correlate to functional decline. 61% of cancer survivors are over age of 65. In the United States, 12.4% of the population (35 million people) is currently over 65, and this demographic will double by 2030 to 70 million (20%). As people age with greater longevity, there are concurrently more co-morbidities.

The Challenge
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The greatest of the many barriers to effective long-term survivorship care is the lack of awareness.

After completing their therapy, some patients wish to distance themselves from their cancer and do not wish to continue in a follow up program. Many cancer patients seek better ways to reduce their risk and improve their survival through better health and lifestyle practices. The challenge is how to provide and implement ways to improve life-style changes and health outcomes. Oncologists and the medical team (primary physicians/general practitioners, nurse specialists, etc.) can play a key role in cancer detection, treatment, surveillance, and prevention for patient care. Unfortunately only about 20 % of oncologists actively guide survivors on better health practices and lifestyle changes which could improve physical and psychosocial well-being and promote better health, quality of life, and longevity.

Co-morbid conditions can threaten the lives of cancer survivors. Common problems include angina, congestive heart failure, and diabetes. Unfortunately, with the growing trend of US populations to become overweight or obese, more co-morbid problems will increase. African-Americans, the poor, and the elderly are less likely to receive necessary care and, if diagnosed with cancer, or other co-morbid conditions may not receive appropriate attention (resulting in a 10% decline in 5-year survival rates for these groups).

Survivors are also at risk for psychological and physiological changes which include potential organ dysfunction (kidney, heart, and lung), potential impaired immune response system, sexual dysfunction, cognitive changes, fatigue, depression, anxiety, and family distress, as well as economic challenges related to insurance, job security, and monetary survival.

There is also a lack of awareness about survivorship issues. A multidisciplinary team approach and a variety of delivery systems are needed to address the medical, psychosocial, and lifestyle components of survivorship care.

The goal is to provide tools for patients and their medical team to help chart the course forward to healthy survivorship.
From this review, current knowledge suggests implementation of necessary elements for: cancer survivor guidance planning
healthy lifestyle and initiating measures to reduce risk
and recommendations for follow-up for each cancer

It is important that patients receive a summary cancer survivor care plan reviewing their medical history and treatments, and a set of follow-up recommendations to help guide them over the next twenty plus years with appropriate surveillance and interventions to minimize, and hopefully prevent, further problems. This includes information on their diagnosis and therapy, recommendations for screening, a list of potential side effects related to their cancer therapy, and clinical advice and guidance.

The issues raised by long-lived survivors and their significant potential for co-morbidities will be further exacerbated by the coming of age of the baby boomer generation, the first of which will turn 65 in 2011 (born between 1946 - 1964). A concerted effort is needed to reduce the impact of cancer.

Ways to Improve Health and Longevity
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1.Collect statistics on co-morbid health and follow up screening of survivors, assess treatment results and quality of life, and promulgate best practices. 3
2.Collect and analyze data on disability and dysfunction due to age to identify ways to improve function and quality of life. 3,4
3.Promote better lifestyles (diet, exercise, smoking cessation, limited alcohol, and reduced sun exposure) and screening for co-morbid diseases, cancer recurrence, a new cancer and co-morbidities.
4.Reduce and improve treatments of side effects of therapy and cancer (lymphedema, sexual dysfunction, fatigue, memory problems, and mucositis) and late sequellae side effects (cardiac, osteoporosis, pulmonary fibrosis)
5.Improve survival by reducing co-morbidities and treatment side effects (using improved treatments such as sentinel node biopsies, adjuvant therapies, and new drug treatments to promote longevity, quality of life, and survival.

The Goals
The goal is to improve the research on aging cancer survivors and to improve survival and quality of life with better treatments to ameliorate side effects and provide coping mechanisms through health team education. Hopefully, survivors will have reduced suffering, preventable health problems and fewer premature deaths by implementing healthy lifestyle prevention programs and improved follow-up surveillance programs.

Prevention Measures
It is just as important to make and implement positive recommendations for cancer prevention as it is to diagnosis and treat cancer. By preventing cancer, one is often spared the devastation of suffering, psychological and physical morbidity, as well as extreme expenses, and the debility of illness.

Primary Prevention
Prevention of cancer, for example, with a prudent-type diet, smoking cessation, reduction of alcohol use, reduction of excess sun exposure, and exercise to help decrease morbidity risks.

Secondary Prevention
Screening programs for cancer and disease: cervix, breast, colon, melanoma, prostate lung, osteoporosis and for other secondary malignancy after cancer therapy.

Examples include: Increased risk for breast cancer many years following chest mantle radiotherapy for Hodgkin's disease therapy merits long-term breast cancer detection follow-up; dental preventive care especially when using Zometa for bone pain and osteopenia/osteoporosis.

Tertiary Prevention
Early detection, surveillance, and management of late cancer toxicities post radiotherapy, chemotherapy, and/or targeted-therapy (for example, adriamycin, epirubicin, bleomycin, and Herceptin which can have late toxic side effects).

For example: Zinecard is a drug used to reduce Adriamycin or Epirubicin cardiac toxicity.

Osteoporosis prevention with diet/vitamins/calcium and/or biphosphonates treatment, and follow-up with an osteoporosis assessment and a DEXA (Dual Energy X-ray Absoptometry) bone density test for evaluation of bone density and treatments are recommended.

1. Haylock, P.J., The Shifting Paradigm of Cancer Care, American Journal of Nursing, March 2006, Vol. 106, No. 3 supplement, pg. 16-19
2. Brown, B.V. and M.C. Brauner, Noncancer Deaths in White Adult Cancer Patients. Journal of the National Cancer Institute, 85:979 -997, 1993
3. From Cancer Patient to Cancer Survivor, Lost in Transition, 2005, Committee on Cancer Survivorship: Improving Care and Quality of Life, National Cancer Policy Board; Maria Hewitt, Sheldon Greenfield, and Ellen Stovall, editors. Institute of Medicine, National Research Council, Washington, D.C. The National Academies Press.
4. Sweeney, C., K. H. Schmitz, D. Lazovich,, Functional Limitations In Elderly Female Cancer Survivors, Journal of the National Cancer Institute, Vol 98, No.8, Apr 19, 2006 P521-29

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First appeared June 29, 2006; updated March 4, 2008; reviewed July 20, 2014