Cancer Survivor Care

Aka: Cancer Survivor Care, Cancer Survivor, Childhood Cancer Survivor, Adult Cancer Survivor

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II. Epidemiology

  1. Adult Cancer survival rates >5 years are high for some common cancers (U.S., 2003-9)
    1. Prostate Cancer 5 year survival: 99.2%
    2. Melanoma 5 year survival: 91.3%
    3. Breast Cancer 5 year survival: 89.2%
    4. Hodgkin Lymphoma: 85.1%
    5. (2015) SEER, NCI
      1. http://seer.cancer.gov

III. Precautions

  1. Childhood Cancer treatments are associated with a 4-fold increased risk of chronic disease over their siblings
    1. Cancer Survivors have a biological age that is advanced 10-15 years beyond their Chronological age
    2. Diabetes, Coronary Artery Disease, Hypertension and Hyperlipidemia present in the 30s of Childhood Cancer Survivors
  2. Secondary cancers develop in 20% of Cancer Survivors (related to Chemotherapy or radiation)
    1. Alkylating Agents and topoisomerase II inhibitors
      1. Associated with aggressive, poor-prognosis Leukemias (typically AML) within 10 years of initial cancer treatment
    2. Radiation Therapy
      1. Tumor development in region of radiation 15-20 years after radiation treatment

IV. Adverse Effects: Survivors of Childhood Cancers

  1. Skin Effects from Radiation Therapy
    1. Dysplastic Nevi
    2. Skin Cancer
  2. Ocular Effects from Bisulfan, Corticosteroids, Radiation or neurosurgery
    1. Cataracts
    2. Retinopathy (Radiation Therapy >30 Gy)
    3. Ocular nerve palsy (neurosurgery related)
  3. Auditory Effects from Cisplatin, Carboplatin, Radiation (>30 Gy)
    1. Sensorineural Hearing Loss
    2. Conductive Hearing Loss (Radiation Therapy)
  4. Dental Effects from radiation or early Chemotherapy prior to seconday Dentition
    1. Dental development effects or Periodontal Disease
    2. Osteoradionecrosis (Radiation Therapy >40 Gy)
  5. Cardiovascular Effects
    1. Anthracycline (e.g. Doxorubicin, Daunorubicin) related
      1. Congestive Heart Failure (associated with 50% mortality in 2 years after diagnosis)
      2. Cardiomyopathy
      3. Arrhythmia
    2. Radiation Therapy related
      1. Valvular disease
      2. Coronary Artery Disease
      3. Pericarditis
  6. Pulmonary Effects from radiation, lobectomy or Bleomycin, Busulfan, or nitrosureas (Carmustine/BCNU and Lomustine/CCNU)
    1. Pulmonary fibrosis
    2. Interstitial pneumonitis
    3. Restrictive Lung Disease
  7. Breast Effects from radiation
    1. Breast tissue hypoplasia
    2. Breast Cancer (Radiation Therapy >20 Gy)
  8. Gastrointestinal Effects from laparotomy, radiation (>30 Gy)
    1. Chronic Colitis
    2. Intestinal Stricture
    3. Abdominal adhesions
    4. Fecal Incontinence
    5. Colon Cancer (Radiation Therapy >30 Gy)
  9. Liver Effects from Mercaptopurine, Thioguanine, Methotrexate or radiation (>30 Gy)
    1. Liver function abnormalities
    2. Veno-occlusive disease
    3. Hepatic Fibrosis
    4. Cirrhosis
    5. Cholelithiasis
  10. Renal Effects from Cisplatin, Carboplatin, Isosfamide, Methotrexate, nephrectomy or Radiation Therapy
    1. Glomerular toxicity
    2. Tubular dysfunction
    3. Renal Insufficiency
    4. Hypertension
  11. Bladder effects from Cyclophosphamide, isofosfamide, radiation, Spine Surgery or cystectomy
    1. Hemorrhagic cystitis
    2. Bladder fibrosis
    3. Neurogenic Bladder
    4. Bladder Cancer (Radiation Therapy or Cyclophosphamide)
  12. Male reproductive effects from Alkylating Agents, radiation, surgery
    1. Arrested Puberty
    2. Hypogonadism
    3. Infertility
    4. Erectile Dysfunction
  13. Female reproductive effects from Alkylating Agents, radiation, surgery
    1. Arrested Puberty
    2. Premature Menopause
    3. Infertility
    4. Uterine vascular insufficiency (Radiation Therapy)
    5. Vaginal stenosis (Radiation Therapy)
  14. Endocrine effects from radiation (pituitary, neck), Thyroidectomy
    1. Growth Hormone Deficiency
    2. Precocious Puberty
    3. Hypothyroidism
    4. Thyroid Nodules and Thyroid Cancer
    5. Hypoprolactinemia (radiation >40 Gy)
    6. Central Adrenal Insufficiency (radiation >40 Gy)
    7. Gonadotropin deficiency (radiation >40 Gy)
    8. Hyperthyroidism (radiation >40 Gy)
    9. Diabetes Mellitus (full body or abdominal radiation)
  15. Musculoskeletal effects from Corticosteroids, Methotrexate
    1. Osteoporosis
    2. Osteonecrosis
  16. Musculoskeletal effects from Radiation Therapy
    1. Radiation induced Fractures (>40 Gy)
    2. Scoliosis or kyphosis
    3. Secondary musculoskeletal cancers
    4. Reduced function or uneven growth
  17. Neurologic effects from Methotrexate or cytaribine (doses >1000 mg/m2), radiation or neurosurgery
    1. Cognitive deficits, IQ Effects and Learning Disorders
    2. Leukoencephalopathy
    3. Cerebrovascular Disease (neck or upper chest radiation)
    4. Brain Tumors
  18. Peripheral Nervous System effects from Vincristine, Vinblastine, Cisplatin, Carboplatin or Spine Surgery
    1. Peripheral Neuropathy
  19. Immunologic effects from radiation to Spleen, or splenectomy
    1. Asplenia
  20. References
    1. (2009) Pediatrics 123(3): 906-15 [PubMed]

V. Management: Monitoring

  1. See Bladder Cancer
  2. See Breast Cancer Survivor
  3. See Colorectal Cancer
  4. See Prostate Cancer Survivor Care
  5. See Melanoma
  6. See Thyroid Cancer
  7. See Non-Hodgkin's Lymphoma
  8. See Hodgkin's Lymphoma
  9. See Acute Myeloid Leukemia
  10. See Acute Lymphoblastic Leukemia
  11. Breast Cancer Screening in Cancer Survivors
    1. Indications
      1. Women (assigned female at birth) AND
      2. Chest, neck, axilla or mantle Radiotherapy (>=30 Gy) before age 25 years
    2. Protocol
      1. Breast MRI and Mammography yearly starting at age 25 years (or 8 years after Radiotherapy)
    3. References
      1. Gao (2023) Radiographics 43(4): e220155 [PubMed]
  12. Colorectal Cancer Screening in Cancer Survivors
    1. Indications
      1. Abdominal or pelvic Radiotherapy (>=20 Gy) before age 30 years
    2. Protocol
      1. Colorectal Cancer Screening starting at age 30 years (or 5 years after Radiotherapy)
      2. Protocols are being established to better decide which exposures best benefit from early screening
    3. References
      1. Teepen (2019) J Natl Cancer Inst 111(11):1114-5 +PMID: 30980664 [PubMed]

VI. Management: Adverse Effects in Cancer Survivors

  1. Mood Disorders (29%)
    1. See Cancer Related Mood Disorders
    2. Screen for Major Depression (e.g. PHQ-9)
    3. Screen for Anxiety Disorder (e.g. GAD-7)
    4. Screen for Substance Abuse (e.g. DAS-10, AUDIT-C, CAGE Questions)
    5. Consider PTSD Screening (e.g. Post-Traumatic Stress Disorder Screening Tool)
    6. Be alert for Mood Disorder changes at times of stressors
    7. Manage contributing factors (e.g. pain, Insomnia)
    8. Consider mental health counseling and medication therapy (e.g. SSRI)
  2. Mild Cognitive Impairment
    1. See Cancer Related Delirium
    2. Typical cognitive screening tools (e.g. MMSE) poorly correlate with cancer-related cognitive dysfunction
    3. Evaluate for reversible causes (e.g. Insomnia, Mood Disorder)
    4. Consider Neuropsychological Testing
    5. Consider cognitive rehabilitation (e.g. occupational therapy, speech therapy, neuropsychology)
    6. Consider psychotherapy
  3. Fatigue
    1. See Cancer Related Fatigue
    2. Fatigue may persist for months to years following cancer treatment
    3. Evaluate and treat underlying causes (e.g. Anemia, Insomnia, stressors, pain, Hypothyroidism)
    4. Consider medication adverse effects
    5. Encourage regular Physical Activity
  4. Lymphedema (20%)
    1. See Lymphedema
    2. Common after Lymph Node dissections and other cancer surgery
    3. Referral to Lymphedema therapist
    4. Compression Stockings
    5. Physical therapy for range of motion and Resistance Training guidance
  5. Pain or Neuropathy (20 to 50%)
    1. See Cancer Pain
    2. See Chronic Pain Management
    3. Evaluate region specific causes of pain and exclude new conditions (versus Chronic Pain exacerbation)
    4. Chronic Pain Management focused on functional improvement and realistic goals
  6. Reproductive health and Sexual Dysfunction (18% women, 31% men)
    1. See Female Infertility
    2. See Male Infertility
    3. See Vaginal Dryness
    4. See Vasomotor Symptoms of Menopause
    5. See Erectile Dysfunction Management
    6. Consider reproductive specialist

VII. Prevention

  1. Coordinate care between primary care and oncology
    1. Survivorship care plan
      1. Summary of treatment history and future plan as created by cancer care team
      2. Outlines long-term adverse effects and surveillance for complications, recurrence, secondary cancers
      3. Offers recommendations on prevention, maintenance of well-being, and information on legal protections
    2. Monitoring
      1. Cancer recurrence
      2. New cancers (occurs in 8% of Cancer Survivors, esp. Lung Cancer)
    3. Management
      1. Longterm adverse effects of cancer treatment
      2. Prevention of late Treatment Effects
  2. Cancer Survivors can benefit significantly from more vigilant primary care and preventive care
    1. Cancer Survivors are less likely to be counseled on Tobacco Abuse, diet and Exercise
      1. Grunfeld (2006) 24(6): 848-55 [PubMed]
    2. Cancer Survivors are less likely to have had Influenza screening, lipid screening or Cervical Cancer Screening
      1. Earle (2004) Cancer 101(8): 1712-9 [PubMed]
    3. Cancer Survivors have increased mortality from associated comorbid conditions
      1. Cancer Survivors with diabetes have a 40% increased all-cause mortality over those without diabetes
      2. Barone (2008) JAMA 300(23): 2754-64 [PubMed]
  3. Obtain a Family History
    1. Consider Genetic Counseling for the Cancer Survivor (and their children, siblings) if Family History positive
  4. Screen for psychosocial and neuropsychological conditions (see above)
    1. Major Depression
    2. Anxiety Disorder (including PTSD)
    3. Substance Abuse
    4. Insomnia
    5. Fatigue
    6. Cognitive Impairment
  5. Return to Work
    1. Physical Activity increases likelihood of return to work (NNT 7)
      1. Physical training (walking, Resistance Training, Strength Training, yoga)
      2. Psychoeducational and vocational training are adjunctive in return to work
    2. References
      1. de Boer (2024) Cochrane Database Syst Rev 3(3):CD007569 +PMID: 38441440 [PubMed]
  6. Maintain cardiovascular health
    1. Cardiovascular disease is the leading cause of non-cancer death in Cancer Survivors
    2. Evaluate Cardiovascular Risk Factors
    3. Evaluate cancer treatment related cardiovascular adverse effects (see above)
      1. Consider Electrocardiogram (EKG) or Echocardiogram
    4. Encourage healthy lifestyle
      1. See Healthy Diet
      2. See Physical Activity
      3. Regular Exercise (aerobic Exercise, Strength Training, yoga)
    5. Manage reversible risks for cardiovascular disease
      1. Hypertension
      2. Hyperlipidemia
      3. Tobacco Abuse
      4. Diabetes Mellitus or Metabolic Syndrome
      5. Obesity
      6. Tobacco Abuse
      7. Alcohol Use Disorder

VIII. Resources

  1. Survivorship Guidelines Website
    1. http://www.survivorshipguidelines.org
  2. Survivorship (NCI)
    1. http://www.cancer.gov/about-cancer/coping/survivorship

IX. References

  1. (2009) Pediatrics 123(3): 906-15 [PubMed]
  2. Bhatia (2012) Pediatrics 130(6): 1141-3 [PubMed]
  3. Carek (2024) Am Fam Physician 110(1): 37-44 [PubMed]
  4. Kattlove (2003) CA Cancer J Clin 53:172-96 [PubMed]
  5. Wilbur (2015) Am Fam Physician 91(1):29-36 [PubMed]

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