Skin cancer image

A cancer survivor is "anyone who has been diagnosed with cancer from the time of diagnosis through the balance of his or her life." (1) Continued advances in cancer treatment have led to marked improvements in cure rates, resulting in almost 10 million U.S. cancer survivors. (2) Nearly two thirds of all cancer patients survive for at least five years, and survival rates are much higher for many common types of cancer (Table 1). (2,3) Cancer survivors are at increased risk for recurrence of the original cancer and development of second primary malignancies as a result of cancer therapy and other risk factors. Prolonged monitoring and treatment are warranted for long-term side effects of surgical, radiation, or cytotoxic therapy.

Approximately 70 percent of cancer patients have comorbid conditions, (4) requiring a comprehensive approach to medical care. Family physicians often have established long-term relationships with these patients and their families, and most cancer patients continue to receive medical care from their family physicians. In addition to overseeing care, acting as a patient advocate, and providing support for family members, the family physician can ensure continued surveillance, provision of preventive care, and management of medical problems.

This article provides an overview of ongoing care and follow-up for cancer survivors. It summarizes surveillance recommendations for the detection of recurrent cancer and second primaries, describes monitoring for potential physical and psychosocial complications of treatment, and addresses other considerations such as genetic risk assessment among survivors of breast, colorectal, and prostate cancers, childhood acute lymphoblastic leukemia, and Hodgkin's disease. These cancers were selected as examples based on their high prevalence or high rates of survival. Tables 2 (5,6) and 3 summarize surveillance information.

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Breast Cancer Survivors

More than 2.1 million U.S. women are breast cancer survivors. (2) Current recommendations for surveillance after primary breast cancer include monthly self-examination of the breasts, annual mammography of preserved breast tissue, and a careful history and physical examination every six months for five years, and annually thereafter. (7) Intensive surveillance using laboratory and imaging tests does not improve overall survival or quality of life. (8) Routine surveillance using bone scans, chest radiographs, and blood tests for tumor markers is not recommended. (8)

Breast cancer survivors have an increased risk of second primary cancers involving the ipsilateral and contralateral breast, ovaries, colon, and rectum. (9) Most recurrent breast cancers arise within the first five years following treatment. Recurrence rates are very low in patients with primary tumors smaller than 1 cm and negative axillary nodes. (10) Non-specific symptoms (e.g., weight loss, persistent cough) or physical findings (e.g., breast or chest wall changes, adenopathy) are common indicators of breast cancer recurrence (11) that should be evaluated thoroughly and specifically sought during regular surveillance.

Breast cancer survivors also may develop physical complications of treatment such as lymphedema, premature menopause, neurocognitive changes, and osteopenia or osteoporosis, as well as psychologic distress related to coping and sexuality changes. (9) Up to 30 percent of breast cancer patients treated with chemotherapy experience cognitive effects, sometimes referred to as "chemo brain." (12) These complications warrant discussion and possible intervention with cognitive-behavior therapy or pharmacotherapy. Studies of various treatment strategies are underway. (12) Lymphedema occurs in 20 to 30 percent of breast cancer patients treated surgically (13) and often responds to early conservative management by physical therapists specializing in this condition. (14) Meticulous skin care is recommended to reduce the risk of local and systemic infection arising from impaired lymphatic return. (Additional information is available online at http://www.cancer.org or through the National Lymphedema Network at 800-541-3259.)

Although tamoxifen (Nolvadex) has been demonstrated to reduce the risk of recurrent breast cancers (15) and maintain bone density, (16) it does increase the risk of uterine cancer. Annual monitoring by pelvic examination is indicated. (7) Recent data suggest that the use of aromatase inhibitors (anastrozole [Arimidex]) in post-menopausal, estrogen receptor-positive breast cancer patients may have greater efficacy and fewer side effects than tamoxifen in the adjuvant setting. (17)

Finally, a review of family history may suggest a hereditary component in breast cancer. Approximately 5 to 10 percent of breast cancers are caused by mutations in cancer-susceptibility genes, most commonly BRCA1 and BRCA2. (18) The role of genetics professionals is important in assessing individual genetic risk and the need for specific testing among these patients and their family members. (A directory of professionals can be found online at http://cancer.gov/search/genetics_services/).

Colorectal Cancer Survivors

For the more than 1 million colorectal cancer survivors in the United States, (2) the prompt detection of recurrent disease can result in improved survival and potential cure. The risk of recurrence is highest in the first five years following resection; thus, frequent follow-up and surveillance have been recommended during this time (Table 2). (5,6) Although a recent meta-analysis (5,19) has shown a survival benefit of 19 percent at five years in patients undergoing intensive follow-up, the American Society of Clinical Oncology (20) and the National Comprehensive Care Network (NCCN) (7) guidelines have limited their follow-up recommendations to history taking, physical examination, carcinoembryonic antigen testing, and colonoscopy. Interpretation of the meta-analysis is complicated by the variety of tests and follow-up schedules used in the studies reviewed. While in this meta-analysis more intensive follow-up was associated with an overall survival benefit, it is not possible to infer an optimal combination of tests or frequency of clinical follow-up for intensive colorectal cancer surveillance. (5)

History taking, physical examinations, and carcinoembryonic antigen monitoring are recommended every three months for the first two years following treatment, and then every six months for the next three years (7,20) (Table 2). (5,6) Patients with carcinoembryonic antigen elevations should be investigated with computed tomography (CT), positron-emission tomography, or colonoscopy, as appropriate, to identify the site of recurrence and its potential for resection. Elevated carcinoembryonic antigen levels may precede symptoms by as much as three to eight months. (21) Surveillance colonoscopy is recommended 12 months postoperatively, provided a full colonoscopy was performed before surgery (at six months if otherwise), and then every three to five years if no abnormalities are detected. (7) Use of routine chest radiographs for annual follow-up is not recommended. (7)

Many survivors of colorectal cancer need to adapt to treatment-associated effects such as fecal incontinence and adhesions. Radiation therapy can cause persistent diarrhea and episodic bleeding resulting from radiation proctitis. This may be treated symptomatically (22) with antimotility agents such as loperamide (Imodium). In severe radiation proctitis, a short course of hydrocortisone foam enemas may be beneficial. Family physicians should be alert to the challenges of ostomy care, including issues of body image and sexuality. (23) Consultation with an ostomy specialist can help family physicians develop individualized treatment recommendations and supportive care.