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Overview of cancer survivorship care for primary care and oncology providers

Overview of cancer survivorship care for primary care and oncology providers
Authors:
Raymond Chan, RN, PhD
Larissa Nekhlyudov, MD, MPH
Section Editor:
Patricia A Ganz, MD
Deputy Editor:
Sonali Shah, MD
Literature review current through: Jun 2022. | This topic last updated: Jun 29, 2022.

INTRODUCTION — The term "cancer survivor" has been used variably in the literature; most commonly, a cancer survivor refers to any person who has been diagnosed with cancer. Therefore, survivorship begins at the time of diagnosis and includes the periods of initial treatment with intent to cure, cancer-free survival, chronic or intermittent disease, and end of life care [1].

There are more than 18 million cancer survivors in the United States [2] and 32 million survivors worldwide [3]. This number is expected to grow due to improvements in cancer screening [4], increases in life expectancy following definitive cancer treatment [4-6], and the aging of the population [7,8].

Many studies report that cancer survivors often do not receive the appropriate oncology and primary care services, with evidence of overuse [9-12] and underuse of services [9,10,12-18]. For cancer survivors who are no longer in active treatment, health care needs include surveillance for recurrence, screening for the development of subsequent primary cancers, monitoring and intervention for the long-term and late physical and psychological effects of cancer and its treatment, management of comorbid medical conditions, as well as routine preventive and primary care [19]. Communication and coordination of care is critical in the delivery of cancer survivorship care; unfortunately, there are few data available on how to best provide oncology and primary care in such a coordinated and comprehensive fashion [20].

In this topic, we provide a broad overview of cancer survivorship care and address ways to enhance the care for cancer survivors. For this review, we will concentrate on the care of patients who have completed treatment with curative intent. A detailed discussion on issues in cancer survivorship and topics related to patients with a specific diagnosis is addressed separately. Links to relevant topics are found at the end of this topic. (See 'Further cancer survivorship information' below.)

EPIDEMIOLOGY — In the United States, the number of cancer survivors has increased dramatically from approximately 3 million in the 1970s to over 18 million in 2022 [2,21]. The majority of survivors were diagnosed more than five years ago with 33, 23, 16, and 28 percent diagnosed 0 to <5, 5 to <10, 10 to <15, and 15 or more years previously [22].

The most common cancer types among female survivors include the following [22]:

Breast cancer (44 percent)

Cancer of the uterine corpus (9 percent)

Cancer of the colon or rectum (9 percent)

Thyroid cancer (8 percent)

Melanoma (8 percent)

Among male survivors, the most common cancers include the following [22]:

Prostate cancer (45 percent)

Cancer of the colon or rectum (10 percent)

Melanoma (8 percent)

Bladder cancer (8 percent)

Non-Hodgkin lymphomas (5 percent)

Most cancer survivors are older individuals; approximately two-thirds are aged 65 or older [2]. Approximately 6 percent of survivors are younger than age 40 [2], although this is a growing part of the population of cancer survivors.

COMPONENTS OF POSTTREATMENT FOLLOW-UP — The transition from active treatment to posttreatment care is critical to long-term health. A committee established at the Institute of Medicine (IOM) to examine the range of medical and psychosocial issues faced by cancer survivors defined the following components of survivorship care [1]:

Prevention of recurrent and subsequent primary cancers, and of other late effects.

Screening for cancer spread, recurrence, or subsequent primary cancers.

Assessment of physical and psychosocial late effects.

Intervention for consequences of cancer and its treatment, for example: medical problems such as lymphedema and sexual dysfunction; symptoms, including pain and fatigue; and psychological distress experienced by cancer survivors and their caregivers.

Evaluation of concerns related to employment, insurance, and disability.

Coordination between specialists and primary care providers to ensure that all of the survivor's health needs are met.

GENERAL ISSUES

Risk of recurrence — Following treatment of a primary cancer, survivors are at risk for recurrence. Recurrences may occur at the initial site (ie, a locoregional recurrence) or in a different location (ie, metastatic disease). The timing and patterns of recurrence, particularly of distant disease, vary by cancer type and stage at diagnosis. In most instances, testing to evaluate for distant recurrent disease should not be performed in otherwise asymptomatic cancer survivors.

Surveillance for local recurrence among cancer survivors is often suboptimal.

In one study of 797 breast cancer survivors, the use of mammography in the first year after treatment was 80 percent, but this significantly declined over time [23]. Women seen by a primary care clinician or gynecologist were more likely to undergo mammography in that year [9-11,15,18,23,24]. (See "Approach to the patient following treatment for breast cancer", section on 'Mammography'.)

In a separate study of colorectal cancer survivors, only 17 percent of colorectal cancer survivors received care in line with recommendations from the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) [12]. (See "Approach to the long-term survivor of colorectal cancer".)

For distant recurrence, by contrast, the data indicate that there is overuse of imaging and laboratory testing [9,10], with both oncologists and primary care providers pursuing testing that is not recommended [25].

Risk of subsequent primary cancer — In addition to recurrences of primary malignancies, cancer survivors are at a higher risk for developing a second (or subsequent) primary cancer [26,27]. Patients with the highest risk of developing a subsequent primary cancer includes survivors of head and neck cancers (eg, laryngeal cancer) and Hodgkin lymphoma [27-30]. (See "Second malignancies after treatment of classic Hodgkin lymphoma" and "Overview of approach to long-term survivors of head and neck cancer", section on 'Subsequent primary cancers'.)

Subsequent primary cancers in cancer survivors occur due to multiple clinical factors, including prior treatment for the primary cancer (eg, chemotherapy, radiation therapy [RT]) [26,31-34], lifestyle habits (eg, smoking, obesity) [27], genetic factors [35-37], and human papillomavirus infection [38]. These data suggest an opportunity for primary care physicians to reduce or prevent the risk of subsequent primary cancers in cancer survivors through lifestyle interventions (eg, smoking cessation, alcohol counseling, diet, and physical activity) as well as cancer screening and genetic counseling [39,40]. (See 'Preventive care' below and 'Screening for subsequent primary cancers' below and 'Genetic implications' below.)

As an example, a retrospective cohort study evaluated the incidence and mortality rates from a subsequent primary cancer among approximately 1.54 million adult cancer survivors from 12 Surveillance, Epidemiology, and End Results (SEER) registries [27]. Among male cancer survivors (excluding those with prostate cancer), compared with the general population, the incidence and mortality rates from a subsequent primary cancer were increased by 11 and 45 percent, respectively (standardized incidence ratio [SIR] 1.11, 95% CI 1.1-1.12; standardized mortality ratio [SMR] 1.45, 95% CI 1.43-1.46). Among female cancer survivors, these incidence and mortality rates were increased by 10 and 33 percent, respectively (SIR 1.1, 95% CI 1.09-1.11; SMR 1.33, 95% CI 1.32-1.34).

Frequency of subsequent primary cancers — Data suggest that lung cancer accounts for a notable proportion of subsequent cancers among both adult and adolescent and young adult (AYA) cancer survivors [27,41]. In one study of 1.54 million adult cancer survivors, lung cancers accounted for approximately one-fifth (19 percent) of subsequent primary cancers and resulted in the highest mortality rates for both males and females (31 and 33 percent, respectively) [27]. Other common subsequent malignancies among male cancer survivors include prostate (14 percent), urinary/bladder (11 percent), and colorectal cancers (10 percent). Among female cancer survivors, common subsequent malignancies include breast (17 percent), colorectal (11 percent), and uterine cancers (7 percent).

Chemotherapy-related cancers — Chemotherapy-related leukemias can occur within two to five years following treatment with alkylating agents, topoisomerase inhibitors, and platinum agents, with risk typically declining after 10 years [35,42]. Alkylating agents can also increase risk of a subsequent primary cancer, including lung, gastrointestinal, bladder, and breast cancers, as well as sarcomas, especially when combined with RT [32,35,43,44].

Radiation-related cancers — Radiation-induced subsequent primary cancers are typically associated with a longer latency period of at least 5 to 10 years after treatment and are associated with the cumulative dose, field of radiation, and age at treatment [34,35,42].

For example, in one study of over 23,000 survivors of childhood cancer, with the most frequent diagnoses being acute lymphoblastic leukemia, Hodgkin lymphoma, and astrocytoma, 6.9 percent of survivors experienced subsequent neoplasms over a mean follow-up of 20.5 years [45]. The most common malignancies were breast and thyroid cancers. The frequency of subsequent malignancies decreased by decade of diagnosis (2.1, 1.7, and 1.3 percent for the 1970s, 1980s, and 1990s, respectively), likely as a consequence of fewer individuals receiving radiation and lower doses of radiation administered over time.

Observational data suggest that RT also increases the risk of certain benign tumors among cancer survivors [46-49]. In one study, examples of such benign tumors included uterine leiomyoma among females treated with abdominopelvic RT; osseous and chondromatous neoplasms among survivors of leukemia who had previously received total body irradiation (TBI); and nerve sheath tumors (schwannomas, acoustic neuromas, and neurofibromas) among cancer survivors who had been treated with body or cranial RT [26].

Screening for subsequent primary cancers — Our approach to screening for subsequent primary cancers is described below and is generally consistent with suggested guidelines from the Children's Oncology Group (COG):

Breast cancer screening – For females treated with chest RT, breast cancer imaging with annual mammography and magnetic resonance imaging (MRI) is suggested [50-53]. As an example, the Children's Oncology Group recommends annual mammography screening with adjunct breast magnetic resonance imaging starting at age 25 (or eight years after chest radiotherapy) for survivors of childhood, adolescent, or young adult cancer who received 20 Gy or more of chest irradiation [51]. (See "Screening for breast cancer: Strategies and recommendations", section on 'High risk: Screening' and "Screening for breast cancer: Strategies and recommendations", section on 'Average risk: Screening'.)

While modeling studies suggest that early initiation of annual breast cancer screening in these high-risk individuals might reduce breast cancer mortality by one-half or more in survivors of childhood cancer [52], unfortunately, these at-risk patients often do not receive appropriate breast cancer screening [54]. As an example, one study found that, among female survivors of childhood cancer treated with chest RT, 64 percent of those aged 25 through 39 years and 24 percent of those aged 40 through 50 years had not had mammography screening for breast cancer within the previous two years [55].

Colorectal cancer screening – For survivors treated with RT to the abdomen, pelvis, or spine, or TBI, guidelines from COG recommend initiating surveillance with colonoscopy at age 30, with further interval screening based on clinical findings at colonoscopy [51]. One cost-effectiveness analysis is generally consistent with these guidelines [56]. (See "Tests for screening for colorectal cancer", section on 'Colonoscopy'.)

Lung cancer screening – For patients with a history of RT (TBI, chest, axilla), guidelines from COG suggest yearly pulmonary examinations and discussion of imaging surveillance with computed tomography (CT) of the chest [51]. The clinical criteria for patients at high risk for lung cancer and frequency of surveillance chest CTs in this population are discussed separately. Smoking cessation for cancer survivors is discussed below. (See "Screening for lung cancer", section on 'Our approach to counseling for screening' and 'Smoking cessation' below.)

Central nervous system (CNS) neoplasm surveillance – For asymptomatic children, adolescent, and young adult (CAYA) cancer survivors treated with cranial radiotherapy, there are limited high-quality data supporting the use of MRI surveillance for subsequent CNS neoplasms, including meningioma. Such CAYA survivors should receive a focused history and physical exam related to potential signs and symptoms of CNS neoplasms at one- to five-year intervals. Clinicians who choose MRI surveillance should discuss with individual patients the potential risks and benefits of such surveillance. In a systematic review conducted by the International Late Effects of Childhood Cancer Guideline Harmonization Group, there was insufficient evidence to establish whether early detection of subsequent CNS neoplasms reduces morbidity and mortality, and no recommendation could be given for or against MRI surveillance [57].

Further details on radiation as a risk factor for CNS neoplasms and management of such tumors in pediatric patients are discussed separately. (See "Epidemiology, pathology, clinical features, and diagnosis of meningioma", section on 'Ionizing radiation' and "Risk factors for brain tumors", section on 'Ionizing radiation' and "Overview of the management of central nervous system tumors in children", section on 'Secondary neoplasms'.)

Other cancers – While age-appropriate screening recommendations for other cancers (eg, prostate and cervical) are similar to those for the general population; particular attention should be paid to organs that are prone to radiation effects (eg, skin, thyroid). The approach to screening for thyroid cancer in cancer survivors with a history of thyroid radiation exposure are discussed separately. (See "Radiation-induced thyroid disease", section on 'Approach to the patient with a history of thyroid radiation exposure'.)

Monitoring for late or long-term effects of cancer and its treatment — In addition to subsequent primary cancers, cancer survivors are at risk for other conditions related to both their disease and its treatment, which are of increasing importance as survival rates improve (table 1) [1,5,35,42,58-68].

Late and long-term physical effects of chemotherapy include cardiotoxicity, peripheral neuropathy, hearing loss, infection (particularly for those who are asplenic after treatment), loss of bone mass, and in females, premature menopause [5,42,59-66,69-72]. In general, for the asymptomatic patient, a review of systems and a physical examination are indicated, at least on a yearly basis. Further monitoring such as an echocardiogram may be indicated for some. Specific toxicities related to cancer and cancer treatments, as well as appropriate monitoring, are discussed in more detail elsewhere [73] and are reviewed in the following UpToDate topics, according to system:

Cardiac issues (see "Clinical manifestations, monitoring, and diagnosis of anthracycline-induced cardiotoxicity" and "Cardiotoxicity of trastuzumab and other HER2-targeted agents" and "Cardiotoxicity of radiation therapy for breast cancer and other malignancies" and "Cardiotoxicity of radiation therapy for Hodgkin lymphoma and pediatric malignancies")

Neurologic issues (see "Overview of neurologic complications of conventional non-platinum cancer chemotherapy" and "Overview of neurologic complications of platinum-based chemotherapy" and "Prevention and treatment of chemotherapy-induced peripheral neuropathy")

Hearing loss (see "Hearing loss in children: Etiology", section on 'Ototoxic drugs' and "Approach to the care of long-term testicular cancer survivors", section on 'Ototoxicity' and "Pathogenesis and prevention of aminoglycoside nephrotoxicity and ototoxicity", section on 'Ototoxicity' and "Overview of neurologic complications of platinum-based chemotherapy", section on 'Ototoxicity')

Gynecologic issues (see "Overview of infertility and pregnancy outcome in cancer survivors" and "Overview of fertility and reproductive hormone preservation prior to gonadotoxic therapy or surgery" and "Ovarian failure due to anticancer drugs and radiation")

Infectious issues (see "Long-term care of the adult hematopoietic cell transplantation survivor", section on 'Infection/immunity')

Oncologic issues (see "Second malignancies after treatment of classic Hodgkin lymphoma" and "Radiation-associated sarcomas" and "Second primary malignancies in patients with head and neck cancers")

Bone health issues (see "Bone problems in childhood cancer patients" and "Approach to the patient following treatment for breast cancer", section on 'Evaluation of bone density' and "Side effects of androgen deprivation therapy", section on 'Osteoporosis and bone fractures')

Endocrine issues (see "Endocrinopathies in cancer survivors and others exposed to cytotoxic therapies during childhood")

General issues (see "Cancer-related fatigue: Prevalence, screening, and clinical assessment" and 'Physical and psychosocial well-being' below)

While data are lacking about the potential benefits of early recognition and intervention, earlier identification of cardiovascular late effects could improve long-term function, reduce debilitating symptoms, and potentially reduce mortality [74,75]. Therefore, without appropriate awareness of late effects by patients and/or providers, symptoms may either be discounted and/or attributed to other causes, leading to misinformed evaluation and possibly delayed and/or inappropriate treatment.

Unfortunately, awareness of late and long-term effects of chemotherapy is not optimal, particularly among primary care providers (PCPs), as shown in a study that surveyed 1130 oncologists and 1072 PCPs [76]. While almost all oncologists (95 percent) reported awareness of cardiac dysfunction as a late effect of doxorubicin and peripheral neuropathy as a late effect of paclitaxel (97 percent) and oxaliplatin (97 percent), knowledge of these long-term effects was reported only by 55, 27, and 22 percent of PCPs, respectively. Similarly, most oncologists reported awareness of premature menopause (71 percent) and subsequent malignancies (62 percent) as long-term late effects of cyclophosphamide, compared with only 15 and 17 percent of PCPs, respectively.

In the transition of patients from oncology to primary care settings, PCPs must be informed about the potential late and long-term effects of cancer treatment so that they may be better prepared to recognize and address these among the cancer survivors in their care (table 1). (See 'Coordination of care' below.)

Physical and psychosocial well-being — Cancer survivors have been shown to experience a number of difficulties that can impact general quality of life, including depression, anxiety, fatigue, cognitive limitations, sleep problems, sexual dysfunction, pain, and opioid dependence or use disorder [77-90]. However, the data suggest that these needs are not being appropriately addressed.

A population-based study from the 2010 National Health Interview Survey found that poor physical and mental health-related quality of life were reported by 25 and 10 percent of survivors, respectively, compared with 10 percent and 6 percent of adults without cancer [91].

A number of interventions for cancer survivors have been evaluated, with both psychosocial and exercise interventions [84,92] reporting beneficial effects on quality of life [93]. Providers caring for cancer survivors should ask patients about their emotional well-being and be prepared to offer additional evaluation, treatment, and/or monitoring. Further discussion on specific issues is covered separately.

Psychiatric issues (see "Clinical features and diagnosis of psychiatric disorders in patients with cancer: Overview" and "Management of psychiatric disorders in patients with cancer")

Fatigue (see "Cancer-related fatigue: Prevalence, screening, and clinical assessment" and "Cancer-related fatigue: Treatment")

Cognition (see "Evaluation of cognitive impairment and dementia" and "Cognitive function after cancer and cancer treatment")

Sleep disturbances (see "Evaluation and diagnosis of insomnia in adults" and "Overview of the treatment of insomnia in adults")

Sexual dysfunction (see "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation" and "Evaluation of male sexual dysfunction")

Pain

(See "Overview of cancer pain syndromes".)

(See "Assessment of cancer pain".)

(See "Cancer pain management with opioids: Optimizing analgesia" and "Prevention and management of side effects in patients receiving opioids for chronic pain" and "Cancer pain management: General principles and risk management for patients receiving opioids" and "Psychological, rehabilitative, and integrative therapies for cancer pain".)

(See "Cancer pain management: Role of adjuvant analgesics (coanalgesics)".)

(See "Cancer pain management: Use of acetaminophen and nonsteroidal anti-inflammatory drugs".)

(See "Cancer pain management with opioids: Optimizing analgesia" and "Prevention and management of side effects in patients receiving opioids for chronic pain" and "Cancer pain management: General principles and risk management for patients receiving opioids" and "Psychological, rehabilitative, and integrative therapies for cancer pain".)

(See "Cancer pain management: Interventional therapies".)

(See "Cancer pain management with opioids: Optimizing analgesia" and "Prevention and management of side effects in patients receiving opioids for chronic pain" and "Cancer pain management: General principles and risk management for patients receiving opioids" and "Psychological, rehabilitative, and integrative therapies for cancer pain".)

(See "Cancer pain management with opioids: Optimizing analgesia" and "Prevention and management of side effects in patients receiving opioids for chronic pain" and "Cancer pain management: General principles and risk management for patients receiving opioids" and "Psychological, rehabilitative, and integrative therapies for cancer pain".)

Opioid dependence and use disorder

(See "Cancer pain management: General principles and risk management for patients receiving opioids".)

(See "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis".)

(See "Approach to treating opioid use disorder".)

(See "Medication for opioid use disorder".)

Fiscal well-being — Cancer survivorship results in a significant economic burden, referred to as "financial toxicity" [94-98], even years after the diagnosis [97,99-102]. A systematic review suggests that up to two in three patients can experience some levels of financial toxicity [98]. Therefore, providers should inquire about the financial status of patients and whether financial difficulties exist. If issues are identified, patients should be referred to local community social workers, case managers, and/or other support services [103].

In addition, survivors may face fiscal issues that interfere with the receipt of health care [103-111]. In one study, 25 percent of cancer survivors reported that they used up all or most of their savings in the process of cancer treatment [107]. In addition, 10 percent were unable to pay for basic necessities (eg, food, heat, and housing), while 8 percent delayed or avoided care for cancer due to costs [107]. Among those filing for bankruptcy, the highest out-of-pocket medical expenses were associated with cancer compared with other diagnoses [108]. Finally, at least one study suggests that cancer survivors ≤65 years were more likely to forego medical care due to costs compared with older individuals [109].

A systematic review highlighted a clear association between financial toxicity and psychological symptoms [112]. Although the direction of association is not conclusive, this review reported that people experiencing financial toxicity are three times more likely to experience depression and anxiety. There is also emerging evidence that suggest a potential relationship between financial toxicity and physical symptom burden [113,114].

Beyond issues related to the financing of cancer care and follow-up, the eligibility of cancer survivors for health, disability, life, or long-term care insurance is another critical area of concern. One study found that 12 percent of survivors reported being denied health or life insurance coverage because of their cancer diagnosis [115].

Fertility and parenthood — Cancer therapy may put male and female survivors at risk for infertility. Patients may be concerned about their chances of getting pregnant, suffering a miscarriage, and/or achieving a successful pregnancy outcome. Furthermore, cancer survivors may be fearful that their history of cancer or its treatment will have an adverse impact on offspring conceived after their cancer treatment, such as placing them at risk for malignancy, congenital anomalies, or impaired growth and development. They may also be concerned about the risks of pregnancy on cancer recurrence. For these patients, education regarding reproductive function is an important aspect of their care. This topic is reviewed more broadly separately. (See "Overview of infertility and pregnancy outcome in cancer survivors".)

Further discussion on fertility preservation for those who are undergoing cancer treatment is covered separately. (See "Overview of fertility and reproductive hormone preservation prior to gonadotoxic therapy or surgery".)

Adoption and surrogacy are alternative options for cancer survivors to become parents. (See "Adoption" and "Gestational carrier pregnancy".)

Special considerations for survivors of pediatric cancers — Survivors of pediatric cancers are a growing part of the population of cancer survivors, with approximately 6 percent of all cancer survivors younger than age 40 [2,6]. (See 'Epidemiology' above.)

Adult survivors of childhood cancers have unique needs, which are addressed in other cancer-specific survivorship topics. COG also provides guidance regarding these issues [59].

(See "Approach to the adult survivor of classic Hodgkin lymphoma".)

(See "Overview of non-Hodgkin lymphoma in children and adolescents", section on 'Long-term toxicities'.)

(See "Overview of the outcome of acute lymphoblastic leukemia/lymphoma in children and adolescents", section on 'Long-term follow-up'.)

(See "Overview of cancer survivorship in adolescents and young adults".)

PREVENTIVE CARE — Several studies have compared preventive care received by cancer survivors and those without cancer and have found differences in care by specific cancer type [15-17,116-119]. As an example, compared with patients with no history of cancer, those with a prior history of colorectal cancer (and without evidence of disease for at least five years) were less likely to receive flu shots or undergo colorectal cancer screening [116]. Similar issues related to suboptimal management of comorbid conditions in cancer survivors are discussed below. (See 'Management of comorbid conditions' below.)

Among the topics that might relate to disease prevention in cancer survivors, the roles of diet, physical activity, smoking cessation, and awareness of the management of comorbidities are of paramount importance for the primary care provider (PCP) and oncology team. These are discussed below.

Diet and physical activity — Both diet and physical activity can improve the quality of life and can minimize both disease and treatment-related side effects in cancer survivors. Cancer survivors experience decreased physical activity compared with those without cancer; these factors may be related to higher rates of fatigue, obesity, post-chemotherapy weight gain, and/or physical limitations, among other factors [120]. Therefore, clinicians should screen all adult cancer survivors for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss, which is consistent with the United States Preventive Services Task Force (USPSTF) guidance on obesity for all adults [121].

The role of physical activity and diet in cancer survivorship is discussed separately. (See "The roles of diet, physical activity, and body weight in cancer survivors".)

Smoking cessation — Cancer survivors are at increased risk for subsequent cancers, and the risks are significantly higher among those who continue to smoke [122,123]. Detailed overviews of smoking cessation are covered separately. (See "Overview of smoking cessation management in adults" and "Behavioral approaches to smoking cessation".)

Approximately 12 to 15 percent of cancer survivors are current cigarette smokers [115,124]. As advised for the general population, clinicians should ask all cancer survivors about tobacco use and provide tobacco cessation interventions for those who use tobacco products [125]. Approaches involving both oncology specialists and PCPs may be useful in guiding patients to quit smoking [126]. (See 'Coordination of care' below.)

Limitation in alcohol consumption — Despite the evidence base for the association between alcohol consumption and cancer incidence, there are few data available regarding the association between alcohol and cancer recurrence. Thus, recommendations for limited alcohol intake in cancer survivors are based primarily on reducing the risk for subsequent primary cancers. Specifically, for people who drink alcohol, the American Cancer Society recommends limiting consumption to two drinks per day for males and one drink per day for females [127,128]. (See "Treatment of alcohol use and smoking for cancer survivors".)

MANAGEMENT OF COMORBID CONDITIONS — Providers caring for cancer survivors should monitor for and appropriately manage comorbid medical conditions that were present either prior to cancer treatment or that developed posttreatment. Clinical research is ongoing to evaluate the quality of care for other conditions beyond cancer in the cancer survivor.

There is a higher prevalence of comorbidities in cancer survivors compared with those without a history of cancer (54 versus 45 percent, in one observational study [129]). Among cancer survivors, comorbidity was rated as mild, moderate, or severe in 30, 17, and 7 percent, respectively [1]. Based on Surveillance, Epidemiology, and End Results (SEER) data, comorbidity is more common among lung cancer survivors and less common among breast and prostate survivors, but appears to be more related to aging than cancer status [8].

Data suggest that comorbidities increase the risk of all-cause mortality in patients with cancer [130-133], such as cardiovascular comorbidities and diabetes. For example, the impact of pre-existing diabetes in cancer patients was evaluated in one meta-analysis [130]. Compared with patients with cancer without pre-existing diabetes, those with diabetes had higher risk of death from any cause (hazard ratio [HR] 1.41, 95% CI 1.28-1.55). Another meta-analysis suggested that patients with cancer may have worse adherence to medications for diabetes and other cardiovascular comorbidities, such as hypertension and hypercholesterolemia [134]. (See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults" and "Cancer survivorship: Cardiovascular and respiratory issues".)

Unfortunately, the limited data also suggest that patients with a history of cancer may not be receiving appropriate care for conditions beyond cancer, with evidence of differences depending on the type of cancer survived [116,119]. In one study, being a colorectal cancer survivor was associated with a higher likelihood of receiving suboptimal care for a separate chronic medical condition (eg, congestive heart failure or diabetes; odds ratio [OR] 1.19, 95% CI 1.12-1.27) [116]. In a later update, suboptimal care for comorbid conditions among colorectal cancer survivors persisted, but care of breast cancer survivors' comorbid conditions was as good as that of noncancer controls [119]. The findings for care of prostate cancer survivors' comorbid conditions were mixed.

It is important that care be coordinated between the oncology team and the primary care provider to ensure that attention to medical conditions beyond cancer is being received. (See 'Coordination of care' below.)

GENETIC IMPLICATIONS — Providers should inquire about family history of cancer in cancer survivors at the time of diagnosis and update this information over the course of follow-up. Patients with a personal or family history suggesting a potential familial cancer syndrome should be referred for genetic evaluation and testing. (See "Genetic counseling: Family history interpretation and risk assessment" and "Genetic testing and management of individuals at risk of hereditary breast and ovarian cancer syndromes" and "Genetic testing".)

Genetic factors may be associated with cancer recurrences and the development of subsequent primary cancers. In addition, genetic factors may have important implications for the survivor's family members. While not well-defined based on available evidence, the role of genetic factors and their effect on the development of late effects is being studied [135].

COORDINATION OF CARE — A number of models of cancer survivorship care have been described [136], though there are few empiric data to support any given type [137]. The follow-up of cancer survivors can be shared among the primary care provider (PCP), medical oncologist, and other cancer specialists.

Decisions regarding the need for shared care, mostly oncology care or transitioning to primary care, may be based on the type of cancer and treatment exposures, comorbidities, and other factors [138]. A risk-stratified approach to survivorship care may be necessary [139-141]. For example, certain cancer survivors with more complex and specialized survivorship care, such as head and neck survivors, would benefit from multispecialty and multidisciplinary follow-up care [142]. Rehabilitation providers may play an important role in the prevention and management of symptoms and late effects, while promoting survivor health and well-being. [142,143].

Studies addressing the relationship between clinician specialty and the receipt of appropriate care find that survivors receive appropriate care when visits are shared between a PCP and an oncology specialist [13-16,116]. Patients who are followed by generalists tend to receive more preventive care than do patients who are seen primarily by oncologists [13,14,16,17,144,145]. Furthermore, many cancer survivors are older adults, and PCPs may be better equipped to address comorbidities [116,146].

The roles and responsibilities for survivorship care should be well-delineated for both patients and their providers [147-149], particularly during transitions [1,150]. For survivors, the transition from oncology to primary care settings may be guided by the survivorship care plan (SCP). The SCP is developed by the oncology team at the completion of treatment and is meant to be shared with the patient and his or her providers, including the PCP [1]. Several organizations, including the American Society of Clinical Oncology (ASCO), have developed templates for SCPs. This topic is discussed in more detail separately. (See "Assuring quality of care for cancer survivors: The survivorship care plan".)

FURTHER CANCER SURVIVORSHIP INFORMATION — Oncology and primary care providers should consult with emerging guidelines on cancer survivorship care, including those related to surveillance for recurrences, subsequent primary cancers, monitoring and management of late- and long-term effects, psychosocial care, and heath prevention in the cancer survivor. Such guidelines exist for a number of cancer types, including breast [151], colorectal [152,153], prostate [154,155], head and neck [142,156], and post-transplantation [157], among others. Details are also available in other topics. Links to these topics are listed below.

Approach to the adult survivor of classic Hodgkin lymphoma
Overview of care for adult survivors of non-Hodgkin lymphoma
Long-term care of the adult hematopoietic cell transplantation survivor
Approach to the patient following treatment for breast cancer
Approach to the long-term survivor of colorectal cancer
Approach to the care of long-term testicular cancer survivors
Overview of approach to lung cancer survivors
Overview of approach to prostate cancer survivors
Approach to survivors of epithelial ovarian, fallopian tube, or peritoneal carcinoma
Overview of approach to endometrial cancer survivors
Overview of approach to cervical cancer survivors
Management of late complications of head and neck cancer and its treatment
Overview of approach to long-term survivors of head and neck cancer

General issues related to survivors of many cancer types are discussed in the topics below.

Treatment of alcohol use and smoking for cancer survivors
Assuring quality of care for cancer survivors: The survivorship care plan
Cancer survivorship: Cardiovascular and respiratory issues
Cognitive function after cancer and cancer treatment
Oral health in cancer survivors
Overview of cancer survivorship in adolescents and young adults
Overview of psychosocial issues in the adult cancer survivor
Overview of sexual dysfunction in female cancer survivors
Overview of sexual dysfunction in male cancer survivors
Physical rehabilitation for cancer survivors
The roles of diet, physical activity, and body weight in cancer survivors

Additionally, several organizations have developed cancer survivorship guidelines. (See 'Society guideline links' below.)

SPECIAL CONSIDERATIONS DURING THE COVID-19 PANDEMIC — The COVID-19 pandemic has increased the complexity of cancer care. Important issues include balancing the risk from treatment delay versus harm from COVID-19, minimizing the use of immunosuppressive cancer treatments whenever possible, mitigating the negative impacts of social distancing during care delivery, and appropriately and fairly allocating limited healthcare resources. These and other recommendations for cancer survivors during the COVID-19 pandemic are discussed separately. (See "COVID-19: Considerations in patients with cancer".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female infertility".)

SUMMARY AND RECOMMENDATIONS

The population of cancer survivors is growing and getting older. Surveillance for recurrences and other subsequent primary cancers, disease prevention, management of comorbid medical conditions, and monitoring for physical and psychological effects of cancer treatment are needed. (See 'Introduction' above.)

Following treatment of a primary cancer, survivors are at risk for both locoregional and metastatic recurrences. The timing and patterns of recurrence, particularly of distant disease, vary by cancer type and stage at diagnosis. In most instances, testing to evaluate for distant recurrent disease should not be performed in otherwise asymptomatic cancer survivors. (See 'Risk of recurrence' above.)

Cancer survivors are at higher risk for subsequent primary cancers, warranting close cancer screening and lifestyle interventions in select patients with certain treatment exposures and lifestyle habits. (See 'Risk of subsequent primary cancer' above and 'Screening for subsequent primary cancers' above.)

Late effects of cancer treatment may include cardiomyopathy, peripheral neuropathy, and infertility/menopause, among others. Providers need to remain vigilant about signs and symptoms and offer evaluation promptly. (See 'Monitoring for late or long-term effects of cancer and its treatment' above.)

Psychological effects of cancer are common and may include depression, anxiety, fatigue, cognitive limitations, sleep problems, sexual dysfunction, pain, and opioid dependence or use disorder. Evaluation of symptoms and management are needed. Financial implications on care must be addressed. (See 'Physical and psychosocial well-being' above and 'Fiscal well-being' above and 'Fertility and parenthood' above.)

Lifestyle modifications, including smoking cessation, healthy diet, exercise, and no more than moderate alcohol consumption, are important for cancer survivors. They have been shown to improve patient quality of life, risk of recurrence, and possibly mortality. (See 'Preventive care' above.)

Providers should inquire about family history of cancer in cancer survivors at the time of diagnosis and should update this information over the course of follow-up. Patients with a personal or family history suggesting a potential familial cancer syndrome should be referred for genetic evaluation and testing. (See "Genetic counseling: Family history interpretation and risk assessment" and "Genetic testing and management of individuals at risk of hereditary breast and ovarian cancer syndromes" and "Genetic testing".)

Coordination with primary care, particularly for prevention, management of comorbid medical conditions, and psychosocial care, may be of benefit. Survivorship care plans are a tool that may be used to communicate and guide survivorship care. (See 'Coordination of care' above and "Assuring quality of care for cancer survivors: The survivorship care plan".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Claire Snyder, PhD, who contributed to an earlier version of this topic review.

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Topic 16613 Version 69.0

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