Shifting focus to cancer survivorship in prostate cancer: challenges and opportunities

PURPOSE OF REVIEW: As strides have been achieved in cancer control, issues faced by survivors have become increasingly relevant. Currently, there are more than 10 million cancer survivors living in the US and consequently cancer survivorship has become a major health priority. Approximately 2 million prostate cancer survivors face a host of long-term and late effects following cancer therapy. Although progress has been made in recognizing many of the issues faced by survivors, gaps in comprehensive surveillance and management still exist. RECENT FINDINGS: In its recent report, From Cancer Patient to Cancer Survivor: Lost in Transition, the Institute of Medicine outlined deficits in the care provided to cancer survivors and proposed several mechanisms to improve the coordination and quality of follow-up care. Measures to achieve these objectives include improving communication between healthcare providers through a survivorship care plan, developing an evidence base to better support surveillance guidelines, and assessing different models of survivorship care. SUMMARY: Potential shortcomings in the recognition and management of ongoing issues faced by prostate cancer survivors may impact the overall quality of long-term care in this growing population. Although programs to address these issues have been proposed, they are in the earliest phase of development.     

Providing prostate cancer survivorship care in Japan: Implications from the USA care model

Despite an increasing number of prostate cancer survivors in Japan, the current delivery of prostate cancer survivorship care is insufficient and lacks a multidisciplinary approach. We carried out a study to characterize prostate cancer survivorship care in Japan, examine the Japanese workforce available to deliver survivorship care, introduce a conceptual framework for survivorship and identify opportunities to improve Japanese survivorship care. We systematically searched PubMed for prostate cancer survivorship care studies, including those from Japan. We also searched the internet for prostate cancer guidelines relevant to survivorship care. We found 392 articles, of which 71 were relevant, read in detail and reported here. In Japan, survivorship care is mostly provided by urologists. Primary care as a specialty does not exist in Japan, and there are no independent nurse practitioners or physician assistants to assist with survivorship care. Japanese quality of life studies characterize the long‐term effects of prostate cancer treatment, but routine use of patient‐reported outcomes is not common in Japan. In the USA, in light of a growing comprehensive awareness of challenges facing survivors and their providers, the American Cancer Society prostate cancer survivorship care guidelines serve as a tool for optimizing the management of long‐term treatment effects and coordination of care. In order to deliver high‐quality survivorship care in Japan, urologists need to establish collaborations with other disciplines within the delivery system. A multidisciplinary guideline for prostate cancer survivorship care in Japan appears warranted.     

Brief review: Pain management for cancer survivors: challenges and opportunities

Purpose

As the number of cancer survivors continues to increase due to advances in medicine, many cancer survivors remain on their same pain management regimen long after their cancer treatment has been completed. Thus, the purpose of this review is to encourage awareness of the challenges and opportunities of pain management in cancer survivorship. It is our expectation that these patients will be referred to pain medicine specialists so their pain management can be optimized during the period of survivorship and ultimately improve their quality of life.

Principal findings

Cancer and its treatment can cause significant pain which requires multidrug therapy, including strong analgesics such as opioids. Optimal pain management has been shown to improve the quality of life of cancer patients, and that is also true for cancer survivors. Nevertheless, the appropriate use of pain medications, especially opioids, must be re-evaluated and adjusted during treatment as the patient transitions into survivorship care and thereafter. This may otherwise result in unnecessary opioid use or may even lead to abuse. Fortunately, as cancer treatment is completed and the survivorship period begins, pain improves gradually and the need for pain medication should decrease. Unfortunately, some patients continue to take their potent analgesics during the period of survivorship although it may not be necessary. It is a challenge for pain practitioners who do not see these patients early in their disease or in the recovery period. Nevertheless, this challenge presents an opportunity for pain management providers to educate oncologists to refer cancer survivors to pain centres early during the period of their survivorship. Cancer survivors could then receive optimal care and maintain a better quality of life without having to take unnecessary pain medications.

Conclusions

It is clear that there is a need to improve pain management in cancer patients, particularly in cancer survivors. Pain physicians should play a critical role as part of a multidisciplinary team that cares not only for cancer patients but also for cancer survivors. Optimizing pain management during the cancer survivorship period results in a better quality of life.     

Supportive care after curative treatment for breast cancer (survivorship care): Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications that require supportive care services. In low- and middle-income settings, supportive care services are frequently limited, and program development for survivorship care and long-term follow-up has not been well addressed.As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert panel identified nine key resources recommended for appropriate survivorship care, and developed resource-stratified recommendations to illustrate how health systems can provide supportive care services for breast cancer survivors after curative treatment, using available resources.Key recommendations include health professional education that focuses on the management of physical and psychosocial long-term treatment complications. Patient education can help survivors transition from a provider-intense cancer treatment program to a post-treatment provider partnership and self-management program, and should include: education on recognizing disease recurrence or metastases; management of treatment-related sequelae, and psychosocial complications; and the importance of maintaining a healthy lifestyle. Increasing community awareness of survivorship issues was also identified as an important part of supportive care programs. Other recommendations include screening and management of psychosocial distress; management of long-term treatment-related complications including lymphedema, fatigue, insomnia, pain, and women's health issues; and monitoring survivors for recurrences or development of second primary malignancies. Where possible, breast cancer survivors should implement healthy lifestyle modifications, including physical activity, and maintain a healthy weight. Health professionals should provide well-documented patient care records that can follow a patient as they transition from active treatment to follow-up care.     

Survivorship care after breast cancer treatment--experiences and preferences of Australian women

Follow-up care after breast cancer treatment is becoming more complex as it attempts to address the long-term needs of an increasing number of survivors. Workforce issues in oncology challenge the sustainability of current specialist-based care. This study explores survivors’ experiences with follow-up care and attitudes to alternative models including a tailored survivorship care plan and involvement of primary care physicians and breast care nurses.Twenty women across Australia participated in semi-structured telephone interviews. All continued to attend follow-up visits with a specialist oncologist and reported a high level of satisfaction with care. Participants described a strong reliance on their specialist but were open to an increased role for their primary care physician in a shared model of care. Communication between multidisciplinary team members was perceived as an ongoing problem and there was enthusiasm for a patient-held written survivorship care plan to address this, and to meet information needs.     

中西医结合肿瘤康复多学科门诊模式的初步构建与实践经验探讨

肿瘤康复是帮助癌症幸存人群通过综合康复支持,从而获得更高生活质量的新兴学科.探索与建立符合我国特色与患者需求的肿瘤康复模式是这一学科目前所面临的迫切问题.2015年11月中国老年学与老年医学学会肿瘤康复分会成立,中国中医科学院西苑医院肿瘤科作为学会主委所在单位以及首批肿瘤康复基地,初步构建了中西医结合肿瘤康复多学科门诊...     

Primary care perspectives on prostate cancer survivorship: Implications for improving quality of care

ObjectivesPrimary care providers often care for men with prostate cancer due to its prolonged clinical course and an increasing number of survivors. However, their attitudes and care patterns are inadequately studied. In this context, we surveyed primary care providers regarding the scope of their prostate cancer survivorship care.MethodsThe 2006 Early Detection and Screening for Prostate Cancer Knowledge, Attitudes and Practice Survey conducted by the Michigan Public Health Institute investigated the beliefs and practice patterns of primary care providers in Michigan. We evaluated responses from 902 primary care providers regarding the timing and content of their prostate cancer survivorship care and relationships with specialty care.ResultsTwo-thirds (67.6%) of providers cared for men during and after prostate cancer treatment. Providers routinely inquired about incontinence, impotence and bowel problems (83.3%), with a few (14.2%) using surveys to measure symptoms. However, only a minority felt ‘very comfortable’ managing the side effects of prostate cancer treatment. Clear plans (76.1%) and details regarding management of treatment complications (65.2%) from treating specialists were suboptimal. Nearly one-half (45.1%) of providers felt it was equally appropriate for them and treating specialists to provide prostate cancer survivorship care.ConclusionsPrimary care providers reported that prostate cancer survivorship care is prevalent in their practice, yet few felt very comfortable managing side effects of prostate cancer treatment. To improve quality of care, implementing prostate cancer survivorship care plans across specialties, or transferring primary responsibility to primary care providers through survivorship guidelines, should be considered.     

Health-related quality of life profiles based on survivorship status for head and neck cancer patients

BACKGROUND: As the methodologies for evaluating health-related quality of life (HRQOL) in head and neck cancer patients have matured over the past 10 years, there has been an increasing focus on reporting longitudinal data. These studies have primarily focused on long-term survivors. This study addresses the HRQOL of both long-term and short-term survivors. METHODS: This is a prospective, longitudinal study of 479 head and neck cancer patients followed for at least 3 years after diagnosis. Analysis of longitudinally collected HRQOL scores was based on survivorship status. RESULTS: The HRQOL for 3 survivorship groups: short-term (died <1 year), intermediate-term (died 1-3 years), and long-term survivors (alive >3 years) were different at all time points (pretreatment, 3, 6, and 12 months). Differences were greatest between the short-term and long-term survivors. Long-term survivors demonstrated the best HRQOL and an improving HRQOL trajectory at 12 months. The HRQOL of short-term survivors declined precipitously throughout all available follow-up. Intermediate-term survivors did show some improvement following treatment but had a declining HRQOL trajectory at 12 months. CONCLUSION: The HRQOL profiles of head and neck cancer patients differed significantly depending on survivorship status. Long-term HRQOL results should be analyzed within the context of the results for all of the patients eligible to have been included in the initial study cohort.     

Tailoring survivorship to diverse populations with genitourinary malignancies

Socioeconomic and racial/ethnic disparities in genitourinary malignancies remain a critical problem. Variations in initial and subsequent treatments, including survivorship care, likely contribute to these disparities. While the prevalence of genitourinary cancer survivors continues to grow, heterogeneity in survivorship care threatens to increase disparities. Several social factors, such as insurance status, language, and geography, drive heterogeneity observed in survivorship care. Linguistically tailored, culturally relevant survivorship is an essential component of a multidisciplinary effort to address racial/ethnic disparities among patients with genitourinary malignancies. Survivorship care is an essential component of cancer treatment, however if it is not developed and tested among a diverse patient population, it can lead to a widening of disparities observed among patients with genitourinary malignancies.     

The primary health care physician and the cancer patient: tips and strategies for managing sexual health

There is a large and growing population of long-term cancer survivors. Primary care physicians (PCPs) are playing an increasingly greater role in the care of these patients across the continuum of cancer survivorship. In this role, PCPs are faced with the responsibility of managing a range of medical and psychosocial late effects of cancer treatment. In particular, the sexual side effects of treatment which are common and have significant impact on quality of life for the cancer survivor, often go unaddressed. This is an area of clinical care and research that has received increasing attention, highlighted by the presentation of this special issue on Cancer and Sexual Health. The aims of this review are 3-fold. First, we seek to overview common presentations of sexual dysfunction related to major cancer diagnoses in order to give the PCP a sense of the medical issues that the survivor may present with. Barriers to communication about sexual health issues between patient/PCPs in order are also described in order to emphasize the importance of PCPs initiating this important conversation. Next, we provide strategies and resources to help guide the PCP in the management of sexual dysfunction in cancer survivors. Finally, we discuss case examples of survivorship sexual health issues and highlight the role that a PCP can play in each of these case examples.     

The Evolution of Breast Cancer Navigation and Survivorship Care

Over the last several decades, breast screening, diagnosis, and treatment have evolved. With that evolutionary process, so have the complexities of oncology care, especially from the perspective of more fragmented care occurring. The majority of breast care is outpatient based. The need for patient navigation has heightened as this fragmentation and financial issues set before the oncologist and the patient continue to occur and in many situations increase. Without effective navigation, breast patients can fall through the cracks and not get diagnosed as early as possible, or not receive all appropriate treatment they need. We are also seeing a steady increase in the actual number of breast cancer patients being diagnosed and surviving long term. Unfortunately simultaneous to this happen there is also a growing shortage of oncology specialists in the USA. This results in a need to transition survivors back to their community physicians after the completion of their acute treatment, and to do so in an organized, anticipated manner that prepares the survivor and her PCP and gynecologist, the tools they all need for effective cancer survivorship management.     

Psychosexual care in prostate cancer survivorship: a systematic review

Background

Prostate cancer (PC) is the most common cancer in men. Due to improvements in medical care, the number of PC survivors is increasing. Current literature demonstrates survivors have significant unmet needs including psychosexual care. We assess patients psychosexual needs by systematic review of literature over the past 20 years up to May 2015 in order to see what issues need to be addressed within psychosexual care.

Methods

A systematic review was conducted on PC survivorship and psychosexual care. The search strategy aimed to identify all references related to PC survivorship programme components (parts of survivorship programmes) AND survivorship AND psychosexual concerns. Search terms used were as follows: (PC OR prostate neoplasms) AND (survivorship OR survivor*) OR [psychosexual impairment or sexual dysfunction or erectile dysfunction (ED)] AND [comorbidity or quality of life (QoL)].

Results

The systematic review identified 17 papers, examining unmet needs in psychosexual care post PC therapy.

Conclusions

These findings of this review may change psychosexual care of PC survivors, as national and international guidance is needed.     

Enhancing prostate cancer survivorship care through self-management

The lack of clear roles for prostate cancer survivorship care providers places prostate cancer survivors at significant risk of inappropriate use of services delivered piecemeal by different providers, persistent bothersome symptoms, and silent suffering. Optimizing quality of care for prostate cancer survivors hinges on decreasing fragmentation of care, and providing quality symptom management. This is achieved through comprehensive, appropriate medical, surgical, pharmacological and psychosocial care, coupled with self-management, as highlighted in several recent resources addressing long-term and late effects of treatment. Although further study is warranted, prostate cancer survivors engaging in self-management may reduce the negative impact of prostate cancer in their lives through better quality of care (better symptom management and efficient use of services) and quality of life.     

Financial toxicity in prostate cancer survivors: A national cross-sectional assessment of subjective financial burden

BackgroundIn prostate cancer (CaP) survivorship, subjective financial burden (SFB), an aspect of financial toxicity, has not been studied using a national sample. Our goal was to explore and identify factors associated with patient-reported SFB in CaP survivors.Materials and methodsWe conducted a retrospective, cross-sectional study of 264 adult individuals with a history of CaP that completed the AHRQ - Medical Expenditures Panel Survey - Household Component and Cancer Self-Administered Questionnaire Supplement in 2016 or 2017. Primary outcomes were the presence of cancer-related SFB and the severity of this burden. Multivariable ordinal logistic regression and logistic regression models were used to identify factors associated with the severity of SFB and different domains of burden.ResultsMost participants were non-Hispanic white, had 3 or more comorbidities and had a median age of 72 years. 62.1% of survivors indicated SFB associated with their CaP care and long-term effects. 49.2% of CaP survivors indicated coping SFB, 27.7% psychological, and 29.2% material. Older (OR: 0.95, 95%CI 0.92–0.98) was associated with less SFB. Low-income level (OR: 2.1, 95%CI 1.01–4.36) was associated with higher SFB. Hispanic survivors (OR: 2.8 95%CI 1.1–7.4) indicated more psychologic SFB. Presence of a caregiver was noted as a predictor of material (OR 2.6, 95%CI 1.45–4.49) and psychological (OR: 2.2, 95%CI 1.13–3.91) SFB.ConclusionsMany CaP survivors experience SFB and associated factors differ in domain of financial burden. This provides evidence and groundwork for understanding financial burden and improving the quality of counseling and care for this population.     

Experiences with weight change in African-American breast cancer survivors

Abstract:  Although weight gain is a common side effect of breast cancer treatment, limited empirical data are available on how African-American breast cancer survivors react to changes in their weight following diagnosis and treatment. The purpose of this study was to explore psychological and behavioral reactions to weight change in African-American breast cancer survivors. We conducted a qualitative study to explore reactions to weight change following diagnosis and treatment in 34 African-American breast cancer survivors. Forty-seven percent of women reported gaining weight, 32% reported weight loss, and 21% reported no changes in their weight. Regardless of whether women gained or lost weight, these changes were viewed as stressors that caused psychological distress and health concerns. However, some women had positive reactions to weight loss, especially if they had been heavy prior to diagnosis. Women exercised and changed their dietary behaviors following treatment. Despite this, women reported being frustrated with not being able to control changes in their weight. These results suggest that changes in weight may be a critical component of breast cancer survivorship in African-American women. It may be important to provide African-American breast cancer survivors with information about the causes and implications of weight change and strategies for weight control after treatment as part of their follow-up care.     

Survivorship issues as determinants of quality of life after breast cancer treatment: Report from a limited resource setting

ObjectivesQuality of life (QOL) in breast cancer survivors is affected by various long term sequelae of breast cancer treatment. The present study was conducted with the objectives to estimate prevalence of various survivorship issues, and to identify those which are most predictive of limitations in QOL after completion of primary therapy.Material &MethodsThis study was conducted in 230 breast cancer survivors (BCs) and 112 controls at an academic centre in Northern India. Assessment of QOL was done by SF-36 and FACT-B questionnaires. Survivorship issues were noted from a checklist of 14 commonly reported symptoms. Main outcome measures were (1) frequencies of survivorship issues and QOL scores among three groups of survivors divided on the basis of time elapsed since treatment (<2, 2–5, and >5 year follow up) (2) Issues most predictive of limitations in QOL, identified by stepwise logistic regression analysis.ResultsLonger term BCs showed higher QOL scores as compared to those in early follow up. However their QOL scores remained poorer compared to healthy women. The most prevalent survivorship issues were fatigue (60%), restriction of shoulder movement (59.6%), body and joint pain (63.5%), chemotherapy induced cessation of menstruation (73.3%) and loss of sexual desire (60%). Issues which had maximum impact on QOL scores were emotional distress (r = −11.375), fatigue (r = −9.27) and premature menopause (r = −2.085) and its related symptoms.ConclusionManagement of these issues should be priority areas for supportive care, especially in settings with limited resource.     

Management of side effects during and post‐treatment in breast cancer survivors

Cancer‐related fatigue, insomnia, and cancer‐related cognitive impairment are commonly experienced symptoms that share psychological and physical manifestations. One or more of these symptoms will affect nearly all patients at some point during their course of treatment or survivorship. These side effects are burdensome and reduce patients' quality of life well beyond their cancer diagnosis and associated care treatments. Cancer‐related fatigue, insomnia, and cancer‐related cognitive impairment are likely to have multiple etiologies that make it difficult to identify the most effective method to manage them. In this review, we summarized the information on cancer‐related fatigue, insomnia, and cancer‐related cognitive impairment incidence and prevalence among breast cancer patients and survivors as well as recent research findings on pharmaceutical, psychological, and exercise interventions that have shown effectiveness in the treatment of these side effects. Our review revealed that most current pharmaceutical interventions tend to ameliorate symptoms only temporarily without addressing the underlying causes. Exercise and behavioral interventions are consistently more effective at managing chronic symptoms and possibly address an underlying etiology. Future research is needed to investigate effective interventions that can be delivered directly in clinic to a large portion of patients and survivors.     

Quality of Life in Thyroid Cancer is Similar to That of Other Cancers with Worse Survival

Background

The incidence of thyroid cancer is increasing. As such, the number of survivors is rising, and it has been shown that their quality of life (QOL) is worse than expected. Using results from the North American Thyroid Cancer Survivorship Study (NATCSS), a large-scale survivorship study, we aim to compare the QOL of thyroid cancer survivors to the QOL of survivors of other types of cancer.

Methods

The NATCSS assessed QOL overall and in four subcategories: physical, psychological, social, and spiritual well-being using the QOL-Cancer Survivor (QOL-CS) instrument. Studies that used the QOL-CS to evaluate survivors of other types of cancers were compared to the NATCSS findings using two-tailed t tests.

Results

We compared results from NATCSS to QOL survivorship studies in colon, glioma, breast, and gynecologic cancer. The mean overall QOL in NATCSS was 5.56 (on a scale of 0–10, where 10 is the best). Overall QOL of patients with thyroid cancer was similar to that of patients with colon cancer (mean 5.20, p = 0.13), glioma (mean 5.96, p = 0.23), and gynecologic cancer (mean 5.59, p = 0.43). It was worse than patients surveyed with breast cancer (mean 6.51, p < 0.01).

Conclusions

We found the self-reported QOL of thyroid cancer survivors in our study population is overall similar to or worse than that of survivors of other types of cancer surveyed with the same instrument. This should heighten awareness of the significance of a thyroid cancer diagnosis and highlights the need for further research in how to improve care for this enlarging group of patients.

     

Physical activity patterns and associations with health-related quality of life in bladder cancer survivors

Introduction

Physical activity has been shown to significantly improve health-related quality of life (HRQOL) and survivorship in a variety of patients with cancer . However, little is known about the physical activity patterns of bladder cancer survivors and how these are related to HRQOL in the United States. Our objective was to describe self-reported physical activity patterns and HRQOL and examine the association between these measures in a large cohort of bladder cancer survivors.