Annals of Oncology Advance Access originally published online on June 4, 2008
Annals of Oncology 2008 19(7):1216-1217; doi:10.1093/annonc/mdn384
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editorials |
Cancer survivorship: a challenge for the European oncologists
1 Division of Medical A, National Cancer Institute, Aviano
2 Medical Office, National Cancer Institute, Aviano, Italy
* E-mail: csimonelli{at}cro.it; omaoffice{at}cro.it
Cancer survival is significantly increased all over Europe [1, 2], and the cancer prevalence in Europe is estimated to be 2.6% [3]. In the United States, 
10.5 million subjects are cancer survivors [4]. This estimate is on the basis of the definition that anyone who has been diagnosed with cancer, from the time of diagnosis to the rest of her/his life, is a cancer survivor. However, the research into survivors of adult cancer is in its infancy and little has been done especially outside the United States [5].
Many are the clinical and research implications in cancer survivorship that need to be addressed by the European oncologists.
First, cancer is largely a disease of older persons and the majority of cancer survivors today are older than 65 years [6], thus cancer treatment and survivorship occur in a background setting of comorbidity; therefore, they need a multidisciplinary approach and a strict collaboration between cancer specialized centers and the health care system such as primary physicians and the community-based geriatric services.
Secondly, the impact of the neoplastic disease and cancer treatment on the long-term health of the survivors is substantial. Late effects include organ damage and functional disabilities that result from cancer itself, from therapy or both, include neurocognitive problems, premature menopause, gastrointestinal system dysfunction, cardiorespiratory system dysfunction, sexual impairment, infertility, chronic fatigue and secondary malignancies.
Thirdly, living with cancer has many implications on psychological aspects such as fear of recurrence, experience of isolation, anxiety and depression, body image perception and occupational functioning.
According to the American definition of cancer survivors [4], we are facing two different populations of patients: many cancer survivors live with active or advanced disease, while a large and growing number of them live extended and cancer-free lives. Patients under therapy with active disease may have peculiar problems derived by their situation, even if they have a longer life. In fact, considering the psychological aspects, they have to face the fear and the anxiety derived from the constant presence of cancer, together with the management of chronic treatment; while, considering the clinical aspects, they often have to manage the effects of an active disease and therapy with the clinical implications derived from other eventual comorbidities, and for sure, both cancer and active treatment may have a profound impact on the biology of their organism and on their consequent quality of life (QoL). Considering all these aspects, we believe that a better definition for this patients' population could be ‘persons living with cancer’. Moreover, these patients, in particular the ones on specific treatments, are strictly followed up by and they can obtain quite a good support by the cancer centers. In this particular setting, medical oncologists need to take particular attention to the balance among side-effects of therapy, disease control and patients' QoL. Up to now, one of the primary issue for the oncology has been the response rate to treatment, but it becomes clear that change of outlook and a multidisciplinary approach is mandatory in this setting in order to have an optimal management of living persons with cancer.
Long-term cancer survivors, as well as, disease and treatment-free patients from >5 years have to face the late side-effects of antiblastic or biological therapy including disability derived by the cured disease, the fear of recurrence and the risk of secondary and new malignancies (not related to previous treatments). Usually these patients are still followed up by oncologist for their primary cancer but some of their questions persist, such as What are the most common late effects of the treatments?; Who is at risk?; What proportion of survivors will experience recurrent or secondary/new malignancies? and Do medical, psychosocial or behavioral interventions reduce morbidity in the population? Many of these queries do not yet have an exhaustive answer.
We already have some information on the frequencies and management of long-term sequelae in selective groups of long-term cancer survivors such as breast cancer and Hodgkin survivors [6–8]. In addition, in childhood cancer survivors, there has been a quite bit of research and in fact guidelines are already available [9]. However, in adult cancer survivors, an America Society of Clinical Oncology panel of experts had recently failed to develop definitive screening recommendations for chemotherapy- and radiotherapy-induced cardiac and pulmonary late effects [10]. This report raised the problem related to the development of such guidelines in adult cancer survivors mainly due to the heterogeneity of the population studied. Heterogeneity has been observed even from the psychological point of view. In fact, Bloom et al. [11] have recently demonstrated that overall, long-term survivors experienced a good to excellent QoL, but they pointed out some differences among different survivor subgroups.
We believe that to overcome some of the problems related to the heterogeneity, first we have to strictly define the population to be studied and distinguish the patients with active disease (persons living with cancer) from the disease and treatment-free patients from at least 5 years (cancer survivors); secondly, we believe that the institution of specific clinics devoted to cancer survivors offering integrated research and rehabilitation programs could overcome problems related to the difficulties to contact survivors outside their usually infrequent visit in the traditional cancer hospital and it will guarantee a correct clinical research approach.
As mentioned above, cancer is largely a disease of elderly; moreover, this phenomenon will reach a peak when people born during the period of ‘baby boom’ will be 65 years old and the cancer burden will quickly increase. In this demographic and epidemiologic context, the institution of clinics devoted to cancer survivors might appear an overwhelming effort for the new generation of oncologists. However, we firmly believe that the institution of specific cancer survivor clinics is necessary to start the process. In fact, only specialized cancer centers can develop a nationwide management strategy and rehabilitation programs proposing comprehensive translational studies from research and clinic to health planning, with the involvement of community-based services and primary physicians.
Moreover, cancer specialists are needed to keep the focus on the main issues of cancer survivorships and to use the proper and correct methodology of clinical research indispensable to reach validated results. Therefore, the aims of such clinics will be: (i) to develop new screening programs for the detection of secondary and new cancer; (ii) to develop new research strategies in order to identify biological markers as predictors of cancer survival or disease progression (i.e. genetic and immunological features); (iii) to evaluate the psychological/psychiatric, nutritional and social concerns of these patients, (iv) to share the results with the primary physicians and community-based services and (v) in the end to propose and evaluate new health assistance models for cancer survivors. Finally, these interventions must be implemented through a strict cooperation with cancer patients' associations within a new working model that puts patients and their oncologists side by side for the first time. Only through this collaboration we could really answer to the rehabilitation needs of cancer survivors and improving their care.
Acknowledgements
I, Cecilia Simonelli, corresponding author, on behalf of all my coauthors, Maria A. Annunziata, Emanuela Chimienti, Massimiliano Berretta and Umberto Tirelli, declare to have no financial and personal relationship with other people or organization that could inappropriately influence our work.
References
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