Cancer Survivorship: A Brief Snapshot of the State of the Science

A review of current issues within cancer survivorship was recently published in the New England Journal of Medicine.¹ The target audience of this commentary was primary care physicians, obstetricians-gynecologists, advanced-practice providers, and other specialists who may encounter patients with a history of cancer. However, this article has numerous implications for oncology nurses caring for patients who have a history of cancer. I found the following points illustrative:

• The rising numbers of survivors (i.e., from 15.5 million in 2016, to 26.1 million in 2040) will predominantly be elderly—in their 60s, 70s and 80s.²
• Caregivers of survivors (sometimes referred to as “secondary survivors”) are unpaid, woefully underserved, essential, unsung heroes who frequently suffer adversity during the cancer experience; caregiver numbers will escalate in the future in tandem with survivor projections; considerable resource mobilization is required to meet their many unmet needs.³
• There are currently five predominant survivorship care models in practice, none of which have been deemed more effective than the others:⁴ In-clinic primary oncologist continued follow-up Advanced practice provider (APP) survivor follow-up care given at the primary site where the survivor received their cancer treatment APP survivor follow-up care in a separate or stand-alone site other than where the cancer treatment was given Shared provision of follow up where both the primary oncologist and primary care provider (PCP) coordinate ongoing care Follow up care provided within a multispecialty clinic where the survivor has access to numerous specialists depending upon their identified issue or need.
• An emerging concept within survivorship care planning is risk stratification whereby survivors are assigned to low-risk, intermediate-risk, and high-risk categories.⁵ This assignment is based on the nature of the treatment received, likelihood of long-term and late effects, and risk for recurrence. Risk assignment influences the type and timing of survivor follow-up.
• While survivorship care plans serve as an important communication conduit, their efficacy remains questionable.⁶ To-date research has not established the care plan’s positive impact on quality of life and distress reduction following care plans’ implementation.
• Considerably more emphasis should be put on health promotion in survivors.⁷ Strategies that improve overall health also have links to numerous cancers. Hence, focusing on these approaches has twofold potential: increase general health and reduce risk of cancer. These efforts include: Weight management Increased physical activity Smoking cessation Reduced alcohol consumption.

As one of the newest approaches in the management of cancer, the field of survivorship is still a work in progress. It is imperative that we keep abreast of ongoing findings that inform us of new problems and interventions our patients face along the cancer continuum. It is highly likely that oncology nurses in the future will be expected to be as competent and confident in their skills in survivorship care as they are in their mastery of administering cancer therapies and managing their sequelae.

References:

• Shapiro CL. Cancer survivorship. N Engl J Med. 2018 Dec 20;379(25):2438-2450. doi: 10.1056/NEJMra1712502.
• Bluethmann SM, Mariotto AB & Rowland JH (2016). Anticipating the ‘silver tsunami’: Prevalence trajectories and comorbidity burden among older cancer survivors in the United States. Cancer Epidemiol Biomarkers Prev, 25: 1029-1036.
• Boyle D. The caregiving quandary. Clin J Oncol Nurs, 21(2): 139, 2017.
• Halpern MT, Viswanathan M, Evans TS et.al. (2015). Models of cancer survivorship care: Overview and summary of current evidence. J Oncol Pract, 11(1): e19-e27.
• Frobisher C, Glaser A, Levitt GA et.al. (2017). Risk stratification of childhood cancer survivors necessary for evidence-based clinical long-term follow-up. Br J Cancer, 117: 1723-1731.