The American Cancer Society reports there will be about 1,479,000 new cancer cases in 2009 and the five year survival rate for all cancers has reached 66%, up from 50% in 1977. Since the short term survival rate is higher, the number of living cancer patients will grow by over 1,000,000 people this year, surpassing 12 million.
Cancer survivorship is receiving more attention, not only because of the substantial number of ongoing patients but also because of recognized shortcomings in comprehensive follow-up care. In response, the Ft. Washington based National Comprehensive Cancer Network, a recognized expert in all things cancer, has taken a step to assure that patients receive better care and that physicians have proper guidance for the long term management of cancer patients.
A 2006 report by the Institute of Medicine, From Cancer Patient to Cancer Survivor: Lost in Transition highlighted failures in delivering comprehensive and coordinated follow-up care to cancer survivors. The report indicated that many survivors are lost in transition from acute treatment to a non-system of fragmented care lacking in evidence based approaches for managing cancer as a chronic condition.
The report recommends the implementation of comprehensive survivorship care plans. Historically, community-based support groups – often initiated by patients – have been the source of educational, counseling, nutrition and other essential services, but survivorship care plans transfer some of that responsibility to health care providers.
Hospital based cancer programs have shown some interest in survivorship but overall cancer survivorship care plans have not caught on widely. Recently though the NCCN took an important step to expand the survivorship initiative. The NCCN is a recognized authority in the development of cancer guidelines and its latest version of colorectal cancer guidelines includes a section specifically dedicated to the principles of survivorship. It covers a wide range of evidence based post acute care activities.
It was written by Crystal Denlinger, MD a medical oncologist and Andrea Barsevick, RN, PhD a nursing researcher, both at the Fox Chase Cancer Center, an NCCN member. “Cancer survivorship is more than surveillance; it’s a comprehensive approach that includes prevention, evaluating symptoms, screening to identify unreported symptoms and traditional surveillance,” says Denlinger.
“It’s also a whole person approach that recognizes the long term biological, psychological and social impact of cancer,” says Barsevick.
The NCCN guidelines include recommendations for the late effect of disease including managing neuropathy, chronic diarrhea or incontinence, and routine monitoring for cholesterol, blood pressure and glucose.
Other sections of the guidelines cover new information on metastatic disease, including KRAS testing, adjuvant chemotherapy and re-evaluation of patients with unresectable disease following chemotherapy.
Some of the revisions, such as the KRAS biomarker recommendations, indicate that cancer care is changing rapidly. There is growing use of adjuvant chemotherapy, off-label use of drugs, and expanding maintenance drug therapy. PhrMA, the drug manufacturer’s trade association, says there are currently 860 cancer drugs in development, and experts say that many of them will be add-ons to existing regimens, not replacements.
As care becomes more elaborate, experts says survivorship care plans will help oncologists stay on top of the status of patients, and they will benefit other specialists. Survivorship care plans are supposed to be a complete record the course of treatment, indicators of treatment response, and forward looking issues such as recovery from toxicities. These items are included in a part of the guidelines that deals with transfers back to primary physicians.
Denlinger acknowledges the importance of primaries: “Cancer patients commonly have chronic diseases that are successfully being managed by their primary doctor and we’re working more closing with them. And when it’s time to transfer care back to them, they need to understand ongoing issues and shared responsibilities.”