There are more than 15 million people living beyond a cancer diagnosis in the United States today. This number is expected to increase to 19 million by 2024. How can medical providers best serve these people? What community supports need to be put in place? What health care policies would ensure equal access to good, ongoing care?
The concept of cancer survivorship as a target for study and advocacy is more than 30 years old. Cancer survivorship is defined as the time from diagnosis through treatment and beyond. It is a broad topic as the key issues depend on many factors, including age of the patient, the type of cancer, anticipated success of the treatment and short- and long-term toxicities of treatment.
The population of cancer survivors, the majority of whom are over 65, will grow in size, will age along with the general population, and become more ethnically diverse.
In 2005, the Institute of Medicine published a major report, “From Cancer Patient to Cancer Survivor: Lost in Transition,” highlighting 10 recommendations directed at clinical care, research and policies for this group. These included labeling cancer survivorship as a distinct phase of cancer care, developing better tools to identify and manage late effects of cancer treatment, and creating scientifically sound, cost-conscious approaches of tracking recurrent or new cancers.
A key recommendation that may be at risk in today’s environment relates to non-discrimination of patients with a history of cancer, with guarantees that they have good access to affordable insurance.
Cancer treatment generally falls into one of two categories: curative or non-curative. In the former group, surgery, perhaps with medicines and radiation, is the common approach. In the non-curative group, medicines and radiation are usually used with the goal being to prolong survival and reduce symptoms.
Each has its own survivorship issues.
When cure is the intent, a common question is: “After my treatment is completed, how will you monitor me for recurrence?” This depends on the specific disease. For example, with breast cancer there have been several studies looking at screening strategies for recurrence, including blood tests and various imaging tests. No approach has been found really to be helpful and current guidelines call for mammography (primarily to look for new cancers, not recurrence), physical exam and attention to symptoms.
For colon cancer, it’s a different story. Here periodic CT scans are done to look for potentially removable and curable liver metastases. Though it doesn’t happen very often, this is one situation where resecting a metastasis can be helpful.
After curative lung cancer treatment, CT scans are done to look for new cancers, since this is generally a high-risk population for second lung cancers.
As expected, there can be many issues after treatment for cancer. Patients may struggle coping with prognosis. There may be family dynamics that need attention. Those involved in survivorship advocacy include family as a major focus of attention.
In the clinic, who best follows patients after treatment for cancer? An oncologist? The primary care doctor? An advanced practice provider skilled in the themes of survivorship?
Most experts promote a collaboration between primary care and the cancer specialist.
In my opinion, good survivorship care is simply good medical care. There should be attention to long-term toxicities from treatment. There should be attention to the psychology of having a cancer history with the prognosis worries that comes with it. But as an oncologist, one of my goals is to get patients as close to normal as possible and not have them become professional patients. I know it will be a new normal, but we should avoid excess testing and proceed by evidence-based guidelines in our follow-up care.
The best survivorship care will be done by good primary care providers with advice as needed from the cancer experts. There will be good access to affordable insurance. And, perhaps, there will be increasing attention to the complexities of geriatric care.
Broader concerns include the need to investigate such issues as what support services are most needed to help survivors and their families access care, as well as live with cancer as a chronic condition; why some populations have poorer outcomes and what health policies and further coordination of care are needed.
Dr. James A. Stewart is chief of hematology-oncology division, Baystate Regional Cancer Program. He is one several Baystate professionals who address issues related to cancer in this space on a rotating basis each month.