Care of cancer survivors
Approximately 65% of people diagnosed with cancer in Australia will survive more than five years after diagnosis and active treatment.
Objectives of follow-up care are to achieve the following:
- Detection of earlier recurrence
- Examples: Local recurrence of breast cancer in an irradiated breast may be curable by surgery, whereas metastasis to bone is not curable. Therefore, regular mammography is recommended for patients who had previous breast cancers to detect local recurrence as well as contralateral breast cancer; whereas bone scans or CT scans are not recommended.
- Management of side effects and late effects of cancer treatment
- Examples: Patients on aromatase inhibitors are prone to develop osteopenia or osteoporosis. Regular bone densitometry can detect deterioration in bone health that can be treated with bisphosphonates.
- Health promotion for primary and secondary prevention
- Examples: Reduction in the rate of smoking can decrease the risk of further smoking related cancers in patients who survive smoking related cancers, such as head and neck and lung cancers. Follow-up visits also offer opportunities to discuss other lifestyle factors, such as diet and exercise.
- To address other concerns
- Fear of recurrence and uncertainty about the future are common issues that survivors identify as needing help with. A recent (2009) study found that 5 years following diagnosis, most survivors had adjusted well and reported levels of anxiety and depression similar to Australian population norms. A recent meta-analysis suggests that anxiety is more likely to be a long-term problem than depression in both patients with cancer and their spouses compared with healthy controls.
Duration of follow-up varies from cancer to cancer. In addition to history and examination, tumour markers and imaging studies can be useful. In some cancers like breast cancer, extensive imaging studies haven’t been shown to improve survival.
Julie, 62 years, is an early breast cancer survivor currently on aromatase inhibitor therapy following lumpectomy and radiotherapy. Follow-up is to monitor for side effects and late effects of treatment and to detect recurrent disease.
In her case, follow-up should involve:
- history of side effects including arthralgia and hot flushes
- physical examination of breast, axillary and supraclavicular areas to detect early recurrence
- annual breast imaging tests (mammogram and/or ultrasound)
- bone densitometry at required intervals to detect deterioration in bone health due to aromatase inhibitor.
She needs to be reassured that unless she has symptoms suggestive of metastasis, bone scans and CT scans have not been found to improve survival outcome. Survivors’ reactions are individual -- some patients may be reassured by regular follow-up tests, while others may become very anxious. It is important to be aware that annual check-ups can be a cause of stress for cancer survivors and irrespective of their reaction, survivors benefit from the emotional support of a clinician who is willing to listen to their fears and provide an opportunity to talk about how they are feeling.
- Jefford M. Improving outcomes for cancer survivors in Australia. Australia: Cancer Forum; 2009 Nov [cited 2014 Jun 5] Available from: http://www.cancerforum.org.au/Issues/2009/November/Forum/Overview_Improving_outcomes_for_cancer_survivors_in_Australia.htm.
- Cancer Australia. Follow-up after breast cancer. [homepage on the internet] Australia: Cancer Australia; 2012 Sep 17 [cited 2014 Jun 5; updated 2012 Sep 17]. Available from: http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/life-after-breast-cancer/follow-after-breast-cancer.
- Breast Cancer Network Australia. Living with breast cancer. [homepage on the internet] Australia: BCNA; 2010 [cited 2014 Jun 5; updated 2010]. Available from: http://www.bcna.org.au/living-breast-cancer.
- American Cancer Society. How is breast cancer staged? [homepage on the internet] America: American Cancer Society, Inc; 2014 Dec 1 [cited 2014 Jun 5; updated 2014 Dec 1]. Available from: http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-staging.
- Sklar HL. Who gets breast cancer and who survives? [homepage on the internet] WebMD; 2014 Jan 1 [cited 2014 Jun 5; updated 2014 Jan 1]. Available from: http://www.webmd.com/breast-cancer/features/who-gets-breast-cancer-who-survives.
- National Rural Health Alliance, Clinical Oncology Society of Australia. Cancer in rural Australia. Canberra: National Rural Health Alliance; 2012 Jan [cited 2014 Jun 5] Available from: http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-08-cancer-rural-australia.pdf.
- Mitchell AJ. Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis. Lancet Oncol 2013 Jun 5 [cited 2014 Jun 5];14(8):721-732 [Abstract available at http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(13)70244-4/abstract].
- Oeffinger KC, Mertens AC, Sklar CA, Kawashima T, Hudson MM, Meadows AT, et al. Chronic health conditions in adult survivors of childhood cancer N Engl J Med 2006 Oct 12;355(15):1572-82 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17035650].