Cancer survival doesn't end health challenges (ASCO annual meeting)

Earlier detection and better treatments are increasing the success rates for cancer battles. But those treatments have been linked to later varied and often severe medical problems.

By Susan J. Landers — Posted June 20, 2005

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Expanding ranks of cancer survivors have upped the odds that primary care physicians will encounter at least one or two such patients in an average-size practice.

To illustrate: In 1971, an estimated 3 million people made up the group of patients who had combated the deadly disease and lived to tell about it. By 2001, that number swelled to 10 million -- about the same as the population of Los Angeles. And this tally shows every sign of continuing to grow.

The cadre of childhood cancer survivors, for example, long has been recognized as a medical success story. But this group is being joined by more patients whose cancers were diagnosed when they were adults. Most of them are older than 65. Most had breast, prostate, colorectal or gynecologic cancers. And predictions are for 64% of those newly diagnosed to survive for at least five years.

Earlier diagnoses, more effective treatments and the prevention of secondary diseases are all part of this success story, said researchers at the annual meeting of the American Society of Clinical Oncology, held last month in Orlando, Fla.

But the well-recognized health risks of cancer treatments pose follow-up concerns for patients and physicians, said Patricia Ganz, MD, PhD, professor of health services at the University of California-Los Angeles Schools of Medicine and Public Health.

For instance, adults who were treated for childhood cancers in the 1970s and 1980s are five times more likely to have a moderate to severe health problem than their siblings, say new data from the Childhood Cancer Survivor Study. "Most survivors will have future health problems related to their previous cancer therapy, which are likely to increase as they reach their 30s and 40s," said Kevin C. Oeffinger, MD, professor of family medicine at the University of Texas Southwestern Medical Center in Dallas and the study's lead author.

The health problems faced by all survivors are varied and depend on the type of treatment and the person's age when treated, noted Lois Travis, MD, ScD, a researcher at the National Cancer Institute.

Attention also must be paid to the tissue that was treated, Dr. Ganz said. "We know that certain tissues, for example the gonads, are more susceptible to injury, particularly in youths."

But nearly all tissue can be affected, and there is a broad range of health concerns that include lymphedema, premature menopause, infertility, osteoporosis and fractures, she said.

Second cancers are among the most serious consequences for long-term survivors of childhood cancers, accounting for 10% to 15% of newly diagnosed cancers as adults. Cardiorespiratory complications, while rare, also can also be very serious, Dr. Ganz said.

Treatment summaries, which should accompany all patients who leave an oncologist's office, can guide follow-up care, Dr. Ganz said. Such summaries should include the nature and expected toxicity of treatment. Necessary care does not end when the patient completes cancer therapy, she added.

"Doctors should take into account a survivor's previous cancer and cancer therapy, personal and family medical history, lifestyle habits and other health conditions to develop a life plan to periodically screen for health problems and educate survivors on ways they can reduce risk and maximize their health," Dr. Oeffinger said.

Despite this advice, many patients with childhood cancers are lost to follow-up, said Leslie L. Robison, PhD, associate chair of the Children's Oncology Group, a network of institutions and investigators who identify and treat about 90% of children with cancer.

Despite the best efforts of this group to track 20,720 eligible members, 3,017 fell through the cracks. The important message is "we shouldn't lose them in the first place. We must maintain contact," Dr. Robison said.

Cancer survivors don't have just medical needs. The majority of more than 1,000 two-year survivors surveyed by the Lance Armstrong Foundation said they also had psychosocial needs that were largely unmet by physicians. The findings were presented at the ASCO meeting.

Seventy percent said they were depressed because of their cancer, and 53% said the emotional issues surrounding their disease were more difficult to handle than its physical effects or its treatment.

"Patients who experience the psychosocial or other nonmedical problems need to discuss these issues with their physicians and ask for a referral to the appropriate resources," said Steven N. Wolff, MD, professor of medicine at Meharry Medical College in Nashville, Tenn., and the study's lead author.

Forty-three percent said their income had decreased, and one-quarter said they had gone into debt because of the illness' consequences, with 24% reporting that they had incurred debt of $10,000 to $24,000. Fifteen percent set this amount from $25,000 to $49,000.

But the survey also revealed that respondents were optimistic about life. Nearly half said that, as a result of their experience, they are leading a better life. "Dealing with cancer is an experience that changes people's lives forever," said Doug Ulman, director of survivorship at the Lance Armstrong Foundation and a cancer survivor.

ASCO has taken steps to address cancer survivors' needs by forming a task force to coordinate activities within the organization.

The task force, which is co-chaired by Dr. Ganz and ASCO President Sandra J. Horning, MD, professor of medicine at Stanford University and a cancer survivor, will direct a revision of the society's training curriculum and develop clinical practice guidelines on long-term care and the proper monitoring of these patients.

ASCO's already updated core curriculum includes follow-up care at the end of treatment, surveillance, screening for second cancers, and monitoring for short-term and long-term toxicity.

The society operates People Living with Cancer, a patient-oriented Web site (link).

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Who are they?

Nearly 10 million people in the United States have survived cancer.

  • 70% are between ages 50 and 85.
  • Approximately 14% were diagnosed more than 20 years ago.
  • 60% are survivors of breast, prostate, colorectal and gynecologic cancers.
  • 24% of adults with cancer are parents who have a child 18 or younger.

Source: National Cancer Institute Office of Cancer Survivorship

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Meeting details

More information about lectures, presentations and other developments at the American Society of Clinical Oncology annual meeting can be found online (link).

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Survivor gap

Increasing survival rates among young children and older adults with cancer are not, unfortunately, reflected among older adolescents and young adults, those between the ages of 15 and 30, said Archie Bleyer, MD, professor of pediatrics at the University of Texas M.D. Anderson Cancer Center in Houston.

Among the explanations for this gap are lack of health insurance coverage as children age out of parents' policies and less access to clinical trials because a majority of young adults receive care at community-based centers rather than academic centers where trials are often conducted.

In addition, poorer understanding of the biology of adolescent and young adult cancers and, perhaps, more advanced disease at the time of diagnosis, have caused this group to lag behind younger and older counterparts, said Dr. Bleyer.

To improve this situation he recommends that physicians:

  • Recognize that cancer does occur during early adulthood and that everyone is at risk.
  • Be aware that young adults often deny symptoms and are too embarrassed to report them.
  • Realize that young adults are the least likely to have adequate health insurance and should be encouraged to maintain coverage.
  • Urge young adults with cancer to enroll in clinical trials.

During a poster session at last month's American Society of Clinical Oncology annual meeting in Orlando, Fla., Dr. Bleyer presented findings showing that those ages 15 to 30 comprise the group least likely to be evaluated promptly for a symptom of cancer and most likely to have a delay in diagnosis.

There is a dearth of specialists trained in treating cancer in this age group, said Dr. Bleyer. And the diseases in this group are unique, he added. "Biologically, the disease is different."

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