The overall incidence and prevalence of cancer have continued to climb over the past 3 decades, with more than 1.5 million Canadians living with or beyond cancer as of 2018.1 Individuals who completed active cancer treatment require ongoing follow-up or survivorship care. Traditionally, survivorship care fell within the jurisdiction of oncology; however, increasing pressures on tertiary care are pushing this responsibility to primary care, often immediately after patients complete acute treatment.2 Randomized controlled trials have shown primary care and specialist care are equivalent in terms of patients’ health-related quality of life and survivor satisfaction, while primary care is more cost effective.3,4 A scoping review found that while primary care providers (PCPs) deliver whole-person care effectively, most PCPs believe their knowledge base is inadequate to provide effective survivorship care.5 This brief article reviews the 4 steps for delivering survivorship care and provides surveillance recommendations for patients with common malignancies so PCPs are supported in caring for these patients (Figure 1).
The 4 steps of survivorship care
Step 1: care knowledge and coordination
The first step in survivorship care is care knowledge and coordination. It is essential for PCPs to understand and document patients’ cancer treatments. Cancer therapies may span surgery, radiation, targeted therapy, endocrine therapy, chemotherapy, and immunotherapy.6-10 Each of these treatments may result in side effects or long-term sequelae that may present early or late in the survivorship trajectory. Side effects, especially those related to immunotherapy, are more easily recognized if clinicians are aware of exposure to specific therapies. Additionally, certain therapies may continue to be administered over the survivorship phase of care and may require specific monitoring and side effect management, such as assessment of bone mineral density and treatment of arthralgias for patients taking aromatase inhibitors.11
Step 2: cancer surveillance
Individuals who had a cancer diagnosis are at a higher risk than the general population of being diagnosed with a second primary cancer given the higher potential for genetic mutations, greater impact of predisposing lifestyle factors (eg, smoking, alcohol use), and health risks of cancer therapies (ie, radiation, chemotherapy).12 Additionally, these patients are at risk of either local or systemic cancer recurrence and should be monitored accordingly. Cancer surveillance includes regular history taking and physical examinations looking for new signs, symptoms, or findings that may indicate recurrence, coupled with appropriate imaging or biomarker assessment. Specific symptoms of recurrence will depend on the type of primary cancer in question and patterns of metastasis and should prompt a diagnostic workup.13-16 Many recurrences become apparent outside regularly scheduled visits, so advising patients to report any new concerning symptoms that persist for longer than 2 weeks is important.17,18 Most lung and colon cancer recurrences appear within 2 years after treatment, and up to 55% of early-stage (I and II) non–small cell lung cancers will recur.19,20 Breast cancer recurrence varies according to molecular subtype, with more aggressive subtypes, such as triple negative, typically recurring 3 to 5 years after diagnosis, while more indolent subtypes, such as luminal A, characteristically recurring many years (often >10 years) after treatment.21,22 Intensity of surveillance for each cancer type reflects patterns of recurrence and the decreasing chance of recurrence over time. Although recommendations may vary by province,23,24 key surveillance strategies for patients who had breast, colon, prostate, or lung cancer are summarized in Figure 2.13-16,25-28 Adherence to these recommendations will depend on patient preference and comorbid conditions that may preclude retreatment in the event of a recurrence.
Step 3: management of long-term side effects of treatment
The management of common long-term side effects of chemotherapy, radiation therapy, endocrine therapy, targeted therapy, and immunotherapy has previously been discussed in other briefs.6-10 Side effects from cancer therapy may present many years after treatment, with the risk of leukemia after chemotherapy peaking at 5 to 10 years29 and a more than 2-fold higher incidence of heart failure observed in patients who received anthracycline chemotherapy as long as 20 years after treatment.30 Primary care providers should screen cancer survivors for the many physical and psychosocial sequelae that can be associated with cancer treatment, ranging from pain to financial toxicity, difficulty returning to work, and impacts on sexual and psychological health.
Cancer survivors are more likely to experience depression and anxiety than the general population, and as such should be screened for these conditions.31,32 More than half of cancer survivors will experience fear of recurrence—a preoccupation with cancer recurrence with resultant hypervigilance for potential physical symptoms that could signal recurrence. Fear of recurrence can be profound and have negative effects on quality of life and function.33 Family physicians should strive to identify fear of recurrence and support patients by normalizing these concerns while simultaneously grounding them with accurate information on diagnosis and prognosis. Cognitive behavioural therapy (CBT) may be beneficial for patients with moderate to severe fear of recurrence.34 Thirty percent of cancer survivors will experience cancer-related fatigue, a subjective sense of exhaustion that impacts an individual’s function that is out of keeping with their level of exertion.35 Management of cancer-related fatigue is primarily nonpharmacologic once contributory medical factors have been addressed. Exercise, CBT, and mindfulness were found to be effective in treating cancer-related fatigue, with psychostimulants such as methylphenidate reserved for refractory cases.12 Approximately 50% of patients perceive cognitive deficits after any type of cancer therapy, although changes in cognition are mostly associated with chemotherapy.36 Cognitive dysfunction may be compounded by coexisting mood or anxiety disorders. Brief cognitive screening tools commonly used for dementia have inadequate discrimination to assess cancer-related cognitive dysfunction; therefore, neuropsychologic testing should be pursued. Management of side effects includes addressing reversable medical causes, validating symptoms, and implementing nonpharmacologic treatments such as coping strategies, exercise, mindfulness, cognitive training, and CBT.12 Methylphenidate, modafinil, or donepezil can be tried if all other interventions have been unsuccessful, although there is limited evidence supporting the efficacy of these agents.37
Step 4: health promotion
Lifestyle and preventive care measures are important for cancer survivors, who are at increased risk of new cancers and chronic disease compared with the general population. However, cancer survivors, even those cared for by family physicians, typically have suboptimal rates of preventive care including cancer screening and lipid level assessment.38 Family physicians should ensure cancer survivors are up to date on all recommended screening measures. Primary care providers are often able to appreciate elevated genetic risk through their knowledge of family members’ medical histories and should correspondingly refer patients to genetic testing or high-risk cancer screening programs when applicable.
Lifestyle measures are important to consider for cancer survivors, including smoking cessation, reducing alcohol intake, sun safety, exercise, and maintaining a healthy weight with a healthy diet. In addition to being a causative agent for new primary cancers, smoking after diagnosis of a malignancy decreases efficacy of cancer therapies, prolongs and worsens radiation therapy side effects, increases the chance of recurrence, increases all-cause mortality, and decreases survival and quality of life.39-41 Smoking cessation is therefore a cornerstone recommendation for all cancer survivors. Moderate alcohol intake (1 to 2 drinks per day) is associated with increased risk of developing several types of cancer, including breast, head and neck, laryngeal, esophageal, liver, and colorectal, and is associated with higher overall mortality.42-44 Breast cancer recurrence rates may be elevated in individuals with an alcohol intake of more than 3 drinks per week, although this risk may be primarily in women who are overweight or have obesity.45 Cancer survivors, where able, are recommended to engage in 150 minutes of moderate activity or 75 minutes of high-intensity exercise per week and strength training 2 times per week. Participation in daily physical exercise can lead to decreased mortality and symptomatic improvement in pain, fatigue, and depression, with improved quality of life.46 Maintenance of a body mass index of less than 30 kg/m2 is associated with a lower risk of disease recurrence and development of new primary malignancies, and a high-quality diet is associated with lower mortality in cancer survivors.44,47
Conclusion
This brief reviewed the 4 steps for survivorship care and specific surveillance recommendations for 4 common malignancies. Following this pathway can help family physicians provide appropriate care to patients who completed cancer therapy.
Footnotes
Competing interests
None declared
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Cet article se trouve aussi en français à la page 469.
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