The document discusses cancer survivorship and the needs of cancer patients after primary treatment. It notes that as cancer treatments have improved, more patients are living longer after a cancer diagnosis. However, survivors still face complex medical, psychological and social challenges. The document calls for improved education, screening and support services to help survivors address long-term effects of cancer and its treatment and live healthy, productive lives. Health systems need coordinated survivorship care plans and providers need guidelines to help survivors manage issues that may arise years after diagnosis and treatment.

1. Dr. Prashant Surkar
Rajiv Gandhi Cancer Inst.
& Research Centre, Delhi
1

2.  Living beyond cancer should be cause for
celebration for the growing population of
patients who have prevailed over cancer and
survived its treatment.
 The challenge for oncologists and other
involved clinicians is to understand and meet
the complex interplay of biological,
psychological, and socioeconomic needs of
our surviving patients.
2

3.  The multifaceted needs of patients demand a
spectrum of actions from clinicians in order to
provide them with a life worth living.
 The number of cancer survivors has increased
more than 3 fold over the past 30 yrs by
improvements in early detection and
therapeutic successes.
 25 million cancer survivors worldwide.
3

4.  Among male survivors, the most-
◦ Common diagnosis is prostate cancer (44%),
◦ Other genitourinary cancers (12%)
◦ Colorectal cancer (11%).
 Among female survivors, the most-
◦ Common diagnosis is breast cancer (43%),
◦ Gynecologic cancers (17%)
◦ Colorectal cancer (10%)
4

5.  Survivors of hematologic malignancies,
melanoma, lung, and other cancers each
represent less than 10% of the population of
cancer survivors.
 1/3rd of the survivors report severe/life-
threatening complications, 30 yrs after
diagnosis of their primary cancer.
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7. 7

8.  Survivorship is a process with predictable
stages, ranging from-
◦ The acute diagnosis and treatment phase,
◦ Through the post therapy phase of watchful
waiting,
◦ And finally to the phase of permanent survival,
when the focus shifts from concerns about risk of
recurrence to those impacting long-term quality of
survival.
8

9.  The National Coalition for Cancer
Survivorship (NCCS) defined survivorship as a
distinct phase along the cancer control
continuum.
 Institute of Medicine’s (IOM) definition of
cancer survivorship focuses on the phases of
cancer care following completion of primary
treatment and lasting until cancer recurrence
or end of life.
9

10.  NCCN’s Definition of Survivorship-
 An individual is considered a cancer survivor
from the time of diagnosis, through the
balance of his or her life.
 Family members, friends, and caregivers are
also impacted.
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11. 11

12.  Education
 Surveillance
 Intervention
 Communication
 Research
 Patient advocacy
12

13.  Education of the cancer survivor, family,
health care providers-
◦ Provides a plan for care, based on the t/t
administered and future health risks.
◦ Promotes healthy lifestyles.
◦ It gives information to assist health care providers,
in understanding future risks and to foster an
effective interaction with the oncology team.
13

14.  Surveillance is required for cancer spread,
recurrence, or second cancers and for long-
term adverse physical, psychosocial &
socioeconomic effects.
 Interventions are required to prevent or treat
consequences of cancer or its therapy.
14

15.  Communication between specialists and
primary care providers is very essential to
ensure that the survivor’s health needs are
met and detailed records are kept about t/t
history.
15

16.  Research is focused on understanding,
preventing & treating adverse consequences
of cancer or its therapy.
 Patient advocacy is required to address
problems related to employment, insurance,
and disability.
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17. 17

18. 1. Health care providers, patient advocates,
and other stakeholders should work to raise
awareness of the needs of cancer survivors,
establish cancer survivorship as a distinct
phase of cancer care, and act to ensure the
delivery of appropriate survivorship care.
2. Patients completing primary treatment
should be provided with a comprehensive
care summary and follow-up plan that is
clearly and effectively explained.
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19. 3. Health care providers should use systematically
developed evidence-based clinical practice
guidelines, assessment tools, and screening
instruments to identify and manage late effects
of cancer and its t/t.
4. Quality of survivorship care measures should be
developed through public/private partnerships
and quality assurance programs implemented by
health systems to monitor and improve the care,
that all survivors receive.
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20. 5. All qualified organizations should support
demonstration programs to test models of
coordinated, interdisciplinary survivorship care
in diverse communities and across systems of
care.
6. Congress should support Centers for Disease
Control and Prevention (CDC), other
collaborating institutions, and the states in
developing comprehensive cancer control plans
that include consideration of survivorship care,
and promoting the implementation, evaluation,
and refinement of existing state cancer control
plans.
20

21. 7. The NCI, professional associations, and
voluntary organizations should expand and
coordinate their efforts to provide educational
opportunities to health care providers to equip
them to address the health care and quality of
life issues facing cancer survivors.
8. Employers, legal advocates, health care
providers, sponsors of support services, and
government agencies should act to eliminate
discrimination and minimize adverse effects of
cancer on employment, while supporting cancer
survivors with short-term and long-term
limitations in ability to work.
21

22. 9. Federal and state policy makers should act
to ensure that all cancer survivors have
access to adequate and affordable health
insurance.
10. The qualified organizations, private
voluntary organizations, and private health
insurers and plans should increase their
support of survivorship research and expand
mechanisms for its conduct.
22

23.  Identifying Late Effects of Cancer Therapy
 Surveillance/Guidelines for Late Effects
 Intervention to Prevent Potential Late Effects
 Promotion of Adjustment and Healthy
Lifestyles
23

24. Changing the Culture of Research
and Care
The PATIENT is as important as the TUMOR 24

25.  Physical/Medical (e.g., second cancers, cardiac
dysfunction, pain, lymphedema, sexual impairment)
 Psychological (e.g., depression, anxiety, uncertainty,
isolation, altered body image)
 Social (e.g., changes in interpersonal relationships,
concerns regarding health or life insurance, job loss,
return to school, financial burden)
 Existential and Spiritual Issues (e.g., sense of
purpose or meaning, appreciation of life)
25

26.  On discharge from cancer treatment, every pt
and his primary health care provider should
receive a written follow-up care plan
including:
◦ The likely course of recovery from t/t.
◦ Recommended periodic testing and examinations
by whom and on what schedule.
◦ Possible late and long-term effects of treatment
and symptoms.
26

27.  Possible signs of recurrence and second
tumors.
 Possible effects of cancer on daily life
(personal relationships, work, mental health)
and available resources for support.
 Potential insurance, employment, and financial
consequences of cancer and referrals to
counseling, legal aid, and financial assistance
if needed.
27

28.  Recommendations for healthy behaviors that
should also be shared with first-degree relatives
to minimize their potential risk of cancer.
 As appropriate, information on genetic
counseling and testing to identify high-risk
individuals who could benefit from more
comprehensive cancer surveillance.
28

29.  As appropriate, information on known effective
chemoprevention strategies for secondary
prevention (e.g., tamoxifen for breast cancer;
aspirin for colorectal cancer)
 Referrals to specific follow-up care providers.
 A listing of cancer-related print or online
information resources and support
organizations.
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32. 32

33.  Cancer t/t can result in diverse cardiovascular
issues.
 Anthracycline-induced heart failure may take yrs
or even a decade to manifest.
 If detected early, anthracycline-induced heart
failure may be responsive to cardioprotective
medications.
33

34.  Having a h/o anthracycline exposure plus
cardiovascular risk factors increases the risk
for progressive heart failure.
 The risk for cardiovascular problems varies
depending on the type of anthracycline used
and the cumulative dose received.
34

35. 35

36.  General anxiety disorder or Adjustment
disorder with anxious mood.
 Panic disorder.
 Post traumatic stress disorder.
 Obsessive Compulsive disorder.
 Major depressive disorder.
 Adjustment disorder with depressed mood.
 Mixed depression mood and anxiety.
36

37.  Non Pharmacological intervention
 Pharmacological treatment
◦ SSRI
◦ SNRI
◦ Tricyclic antidepressants
◦ Benzodiazepines
◦ If fails  Psychiatry referral
37

38.  Especially in
◦ Intrathecal Chemotherapy
◦ Neurosurgical procedures
◦ Brain irradiation
38

39.  Teach enhanced organizational strategies (ie,
using memory aids like notebooks and
planners, keeping items in the same place)
 Instruct patient to multitask at the time of day
when attention and concentration are the
highest.
 Provide information about relaxation or stress
management skills for daily use.
39

40.  Provide assistance for sleep disturbance and
fatigue.
 Routine physical activity.
 Limit use of alcohol and other agents that
alter cognition and sleep.
 Meditation, yoga, and mindfulness based
stress reduction.
 Use of Psycho stimulants
◦ Methylphenydate
◦ Modafinil
40

41.  Definition –
◦ It is a persistent, subjective sense of physical,
emotional, and cognitive tiredness or exhaustion
related to cancer or cancer t/t; that is not
proportional to recent activity and interferes with
usual functioning.
41

42.  Every patient should be screened for fatigue
at regular intervals.
 Severity: 0–10 scale
◦ 0=No fatigue;
◦ 10=Worst fatigue you can imagine
 0-3
◦ None
◦ Mild
 4-6
◦ Moderate
 7-10
◦ Severe
42

43.  CBC
 KFT
 LFT
 Electrolytes
 TSH
 Imaging for recurrence or metastatic workup
 MUGA scan or ECHO
◦ Patients with cardiotoxic drugs
 Chest Xray and oxygen saturation for
pulmonary complaints
43

44.  Treat contributing factors:
◦ Medications/side effects
◦ Pain
◦ Emotional distress
◦ Anemia-Treat iron, B12, folate deficiency, if present
◦ Consider referral/further evaluation for anemia or
cytopenias
◦ Sleep disturbance
◦ Nutritional deficit/imbalance
◦ Comorbidities
44

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46. 46

47.  Neuropathic Pain
 Post operative pain syndrome
 Myalgias
 Arthralgias
 Skeletal Pain
 Myofascial pain
 Gastrointestinal/urinary/pelvic pain
47

48.  General measures:
◦ Adjuvant analgesics
◦ Antidepressants
◦ Anticonvulsants
◦ Opioids
◦ Cognitive behavioral therapy and psychosocial support
◦ For refractory pain, refer to pain management services,
 Local therapies:
 Pharmacologic therapies
◦ Topical patches (lidoderm, capsaicin)
◦ Creams (ketamine and amitriptyline combined)
 Non-pharmacologic therapies
◦ Heat
◦ Ice
◦ Acupuncture
◦ Neurotomy with radiofrequency ablation
◦ Consider transcutaneous electrical nerve stimulation (TENS) unit
◦ Consider dorsal column stimulation
48

49.  Nonpharmacologic
◦ Physical activity
◦ Physical therapy
◦ Heat (paraffin wax, hot pack)
◦ Cold packs
◦ Ultrasonic stimulation
◦ Massage
◦ Acupuncture
 Pharmacologic
◦ Nonsteroidal anti-inflammatory drugs (NSAIDs)
◦ Muscle relaxants
◦ Anti-epileptic drugs (gabapentin, pregabalin)
◦ Serotonin-norepinephrine reuptake inhibitors (SNRIs)
◦ Tricyclic antidepressants (TCAs)
 Consider referral to pain management services, interventional
specialist, physical therapy, physical medicine, and/or rehabilitation
49

50.  For vertebral compression:
◦ General measures:
◦ Vitamin D/bisphosphonates
◦ NSAIDs
◦ Muscle relaxants
◦ Consider vertebral augmentation (vertebroplasty, kyphoplasty)
◦ Consider referral to pain management services, interventional
◦ specialist, physical therapy, physical medicine, and/or rehabilitation
 For acute vertebral compression:
◦ Opioids
◦ Bracing (thoracolumbar sacral orthosis [TLSO], Jewett brace)
◦ Limited bedrest
◦ Weight-bearing exercises when pain improves
◦ Physical therapy
 For chronic vertebral compression:
◦ Weight-bearing exercises
◦ Physical therapy – thoracic and lumbar stabilization exercises
50

51.  For avascular necrosis:
◦ Physical therapy – based on weight-bearing and
range-of-motion restrictions
◦ Opioids
◦ Muscle relaxants if myofascial component
 For osteonecrosis of the jaw:
◦ Referral to oral surgeon
◦ Anti-convulsants
◦ SNRIs
◦ Opioids
51

52.  For gastrointestinal pain:
◦ Consider referral to gastroenterologist
 For chronic pelvic pain:
◦ Consider referral to urologist or gynecologist
◦ Consider physical therapy for pelvic floor exercises
◦ Proper hydration
◦ Bowel regimen
◦ Dorsal column stimulation for chronic cystitis and chronic
pelvic pain
 For dyspareunia:
◦ Consider referral to gynecologist or sexual health specialist.
◦ Consider referral to pain management services,
interventional specialist, physical therapy, physical
medicine, and/or rehabilitation.
52

53.  Referral to lymphedema specialist, if available
 Compression garments
◦ Review fit and age of garments
◦ Ask about weight changes
◦ Progressive resistance training with compression
garments
 Physical therapy with range of motion
 Manual lymphatic drainage
53

54.  Pain may be acute or appear months after
radiation
 Radiation may lead to scarring, adhesions, or
fibrosis
 Differentiate fibrosis from recurrent tumor
 Radiation to a localized area of the body may
cause a chronic pain syndrome in that area
54

55.  Treat according to specific cancer pain
syndrome guidelines, if appropriate-
◦ Physical therapy
◦ Pain medication (non-opioid medications such as
antiepileptics, NSAIDs)
◦ Surgical lysis of adhesions may be indicated in
extreme circumstances
55

56.  Use the lowest opioid dose for the shortest period of time possible, if
opioids are necessary
 Functionality may be a better endpoint for measuring outcomes,
rather than numerical rating of pain
 Re-evaluate the effectiveness and necessity of opioids on a regular
basis
 If there is no improvement in function, or if opioid-induced
hyperalgesia is suspected, recommend gradual tapering of opioids to
help avoid symptoms of withdrawal
 Discussion of gradual tapering should be routine
 Consider establishing pain treatment agreements
 Address medical-related issues due to chronic or high-dose opioids
◦ Endocrine/hypopituitary abnormalities
◦ Testosterone deficiency
56

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58.  If pain occurs, there should be prompt oral
administration of drugs in the following order:
◦ Nonopioids (aspirin and paracetamol);
◦ mild opioids (codeine);
◦ Strong opioids such as morphine, until the patient is
free of pain.
 To calm fears and anxiety, additional drugs –
“adjuvants” – should be used.
 Drugs should be given “by the clock”, that is
every 3-6 hours, rather than “on demand”.
58

59.  Insomina
◦ > 4 weeks
◦ Difficulty falling and / or maintaining asleep
 Excessive sleepiness
◦ Insufficient sleep syndrome
◦ Obstructive sleep apnea
◦ Restless legs syndrome
◦ Narcolepsy, cataplexy.
59

60.  Excessive sleepiness
◦ Allow more time to sleep or increase time in bed
◦ Sleep hygiene education
 Obstructive sleep apnea
◦ Continuous positive airway pressure
◦ Surgery
◦ Oral appliance
◦ Weight loss
◦ Exercise
◦ Refer to sleep specialist
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61.  Insomnia
◦ Non pharmacological
 Sleep hygiene education
 Sleep specialist refferal
 Congnitive behavioral therapy
◦ Pharmacological
 Zolpidem
 Zaleplon
 Eszopiclone
 Ramelteon
 Temazepam
 Doxepin
 Lorazepam
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63. 63

64.  All patients should be encouraged to be
physically active and return to daily activities
as soon as possible.
 Overall volume of weekly activity of at least
150 minutes of moderate intensity activity or
75 minutes of vigorous intensity activity or
equivalent combination.
 2-3 weekly sessions of strength training that
include major muscle group.
64

65.  Avoid physical Activity/Exercise in-
◦ Severe anemia
◦ Immediately after surgery
◦ Worsening physical condition ex: lymphedema
exacerbation
◦ Active infection
65

66.  Physician and/or fitness expert
recommendation
 Supervised exercise program or classes
 Telephone counseling
 Motivational counseling
 Evaluate readiness to change, importance of
change, self-efficacy
 Cancer survivor-specific print materials
 Set short- and long-term goals
66

67.  Assess daily intake of fruits, vegetables, food
with added sugars, processed foods, red meat,
alcohol use, and desserts.
 Encourage informed choices about food to
ensure variety and adequate nutrient intake.
 Recommended composition of diet-
◦ 2/3 (or more) vegetables, fruits, whole grains, or
beans
◦ 1/3 (or less) animal protein
67

68.  Recommended sources of dietary
components:
◦ Fat: plant sources such as olive or canola oil,
avocados, seeds and nuts, and fatty fishd
◦ Carbohydrates: fruits, vegetables, whole grains, and
legumes
◦ Protein: poultry, fish, legumes, low fat dairy foods,
and nuts
 Limit intake of red or processed meat.
 Moderate consumption (3 or less servings per
day) of soy foods.
68

69.  Weight management should be a priority for all
cancer survivors-
◦ Weight gain should be a priority for underweight
survivors.
◦ Maintenance of weight should be encouraged for
normal weight survivors.
◦ Weight loss should be a priority for overweight/obese
survivors.
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70.  These principles apply to cancer survivors,
including those with hematologic or solid tumor
malignancies and those post transplant.
 In the absence of known harm, administration of
inactivated vaccines should be encouraged.
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72.  Live attenuated vaccines
◦ Infuenza
◦ MMR
◦ Zoster
◦ Oral polio
◦ Rotavirus
◦ Oral typhoid
◦ Yellow fever
72

73. ◦ Live, attenuated influenza vaccine (LAIV)
◦ Combined measles, mumps, and rubella (MMR)
vaccines
◦ Varicella vaccine (VAR)4
◦ Zoster vaccine (ZOS)4
◦ Yellow fever vaccine and oral typhoid vaccine for
travel
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