Survivorship in Non–Small Cell Lung Cancer: Challenges Faced and Steps Forward

Improvements in curative therapies and the advent of screening have led to increased numbers of non–small cell lung cancer (NSCLC) survivors. Most survivors have undergone invasive treatment (surgery, radiation therapy, and/or chemotherapy) and carry a higher comorbidity burden than survivors of other cancers. Overall quality of life (QOL) and health-related quality of life (HRQOL) suffer during the treatment phase, with the potential for long-term decline, and both clinical characteristics and treatment impact these measures. Physical and mental components of HRQOL seem to be most at risk for decline. The issues faced by survivors include physical symptoms such as respiratory issues, fatigue, hearing loss, neuropathy, and postsurgical pain; psychological distress leading to depression, financial issues, and poor compliance with recommended guidelines; and fear or risk of recurrence and secondary malignancies. This article summarizes the major issues faced by NSCLC survivors and suggests appropriate management. Future collaborative efforts are needed to further elucidate the complex issues that affect overall QOL and HRQOL in NSCLC survivors and to develop appropriate interventions in this large and diverse survivor population.

Abstract

Improvements in curative therapies and the advent of screening have led to increased numbers of non–small cell lung cancer (NSCLC) survivors. Most survivors have undergone invasive treatment (surgery, radiation therapy, and/or chemotherapy) and carry a higher comorbidity burden than survivors of other cancers. Overall quality of life (QOL) and health-related quality of life (HRQOL) suffer during the treatment phase, with the potential for long-term decline, and both clinical characteristics and treatment impact these measures. Physical and mental components of HRQOL seem to be most at risk for decline. The issues faced by survivors include physical symptoms such as respiratory issues, fatigue, hearing loss, neuropathy, and postsurgical pain; psychological distress leading to depression, financial issues, and poor compliance with recommended guidelines; and fear or risk of recurrence and secondary malignancies. This article summarizes the major issues faced by NSCLC survivors and suggests appropriate management. Future collaborative efforts are needed to further elucidate the complex issues that affect overall QOL and HRQOL in NSCLC survivors and to develop appropriate interventions in this large and diverse survivor population.

NCCN: Continuing Education

Accreditation Statement

This activity has been designed to meet the educational needs of physicians and nurses involved in the management of patients with cancer. There is no fee for this article. No commercial support was received for this article. The National Comprehensive Cancer Network (NCCN) is accredited by the ACCME to provide continuing medical education for physicians.

NCCN designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

NCCN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center‘s Commission on Accreditation.

NCCN designates this education activity for a maximum of 1.0 contact hour. Accreditation as a provider refers to recognition of educational activities only; accredited status does not imply endorsement by NCCN or ANCC of any commercial products discussed/displayed in conjunction with the educational activity. Kristina M. Gregory, RN, MSN, OCN, is our nurse planner for this educational activity.

All clinicians completing this activity will be issued a certificate of participation. To participate in this journal CE activity: 1) review the learning objectives and author disclosures; 2) study the education content; 3) take the posttest with a 66% minimum passing score and complete the evaluation at http://education.nccn.org/node/73240; and 4) view/print certificate.

Release date: September 18, 2015; Expiration date: September 18, 2016.

Learning Objectives

Upon completion of this activity, participants will be able to:

  • Describe issues related to survivorship care of patients with lung cancer

  • Discuss long-term physical and psychosocial symptoms in lung cancer survivors

  • Explain the role of preventive health and physical activity in lung cancer survivors

Although non–small cell lung cancer (NSCLC) remains one of the most common and deadliest causes of cancer in the United States, improvements in curative therapies and the implementation of screening guidelines have and will continue to increase the number of survivors.1,2 Five-year survival rates for NSCLC have improved from 11.4% in 1975 to 17.3% in 2009, approaching 40% for locoregional disease.1,3 Thus, nearly 39,000 patients with newly diagnosed lung cancer in 2013 will become long-term survivors.3

Long-term NSCLC survivors (those >5 years from their diagnosis) are underrepresented in survivorship research efforts, because the historic long-term survival rate in this disease is low and quality-of-life (QOL) research has typically focused on patients with advanced disease.4,5 Most survivors have undergone invasive treatment, including surgery, radiation therapy, and/or chemotherapy, resulting in a higher comorbidity burden compared with survivors of other cancers.5 These treatments and their effects can impact QOL, both temporarily after treatment and permanently. Thus, understanding the challenges faced by NSCLC survivors is more important than ever.

The National Coalition for Cancer Survivorship (NCCS) defined a survivor as a person diagnosed with cancer “from the time of diagnosis and for the balance of life.”6 Survivorship care focuses on health after treatment and encompasses physical, psychological, and socioeconomic issues. There are 4 essential elements of survivorship care, defined by the Institute of Medicine: (1) surveillance for the recurrence of cancer, new primary cancers, and medical and psychosocial late effects; (2) prevention of recurrent or new cancers and of late effects of treatment; (3) intervention for consequences of cancer and treatment; and (4) coordination between oncology specialists and primary care physicians.7 Thus, survivorship care includes attention to issues related to follow-up and surveillance, QOL, late and long-term effects of treatment, secondary and second primary cancers, employment and financial concerns, and the psychological impact of cancer. In NSCLC, the time at which survivorship care begins is not standardized, and national guidelines advocating for survivorship care do not specify a specific time at which this care should begin.8 Based on the NCCS definition, attention to issues related to survivorship should begin at diagnosis and continue throughout the trajectory of the disease course. Attention to all facets of care is important to ensure that NSCLC survivors receive comprehensive survivorship care.

Overall QOL in Lung Cancer Survivors

QOL involves physical, psychological, and social domains, depending on occasion, and spiritual or existential well-being.9 Health-related QOL (HRQOL) is the subjective functional effect of a disease and/or its treatment on a patient.10 According to the 2010 National Health Interview Survey, poor physical and mental HRQOL were reported by 24.5% (approximately 3.3 million) and 10.1% (approximately 1.4 million) of all cancer survivors, respectively, which were significantly higher than for adults without a history of cancer (10.2% and 5.9%, respectively) in a weighted analysis.11

A prospective study of patients with NSCLC who underwent surgery found that physical and mental HRQOL of survivors were lower compared with an age- and gender-matched reference cohort even 2 years after surgery. Interestingly, the physical aspects of HRQOL remained low after surgery, whereas the mental domain improved moderately at 6 months and 2 years after surgery, although remaining lower than that of the matched reference cohort at all time points.12 Lung cancer survivors (1–6 years postdiagnosis) reported lower physical composite scores when compared with a lung cancer screening cohort,12 but a second study13 reported comparable mental composite scores. The lowest mean subscale scores were in physical functioning and role limitations.13 Another study in NSCLC survivors suggested that global QOL and the subscales of physical and functional well-being were significantly decreased compared with baseline levels for up to 3 months postoperatively, but were similar at 3 months posttreatment.14 Interestingly, emotional well-being subscale scores increased 3 months postoperatively despite the prevalence of depression in this population.

Sarna et al4,9 studied QOL outcomes in 142 long-term NSCLC survivors. Nearly 60% of survivors reported comorbidities and 50% had a forced expiratory volume in the first second of expiration (FEV1) of less than 70% of predicted. Despite this, 71% of survivors were hopeful and 50% viewed the cancer experience as a positive life change. However, 22% had distressed mood and 21% of the survivors had severe functional restrictions (confined to their bed/house because of respiratory limitation), suggesting that there is a subpopulation of survivors in need of targeted interventions to improve QOL. Evidence suggests that some NSCLC survivors have permanently reduced long-term HRQOL compared with the age- and gender-matched population without cancer.15 Factors predicting poor QOL after surgery vary by study and include Caucasian race, depression, lower preoperative diffusing capacity of the lungs for carbon monoxide (DLco), gender, baseline prognostic factors (Karnofsky performance scale, weight loss, disease stage, and histology), dyspnea, pain, and nausea.9,14,16,17 Preoperative dyspnea, adjuvant chemotherapy, extensive surgical resection, and comorbidities also predict for worse QOL scores,14,18 The association of continued smoking after diagnosis with QOL has been hypothesized, but studies are inconsistent. In a study by Sarna et al9 that collected data on current and prior smoking in lung cancer survivors, a correlation between QOL and smoking was not established. On the other hand, a meta-analysis of 13 HRQOL studies found a strong negative correlation between QOL and continued smoking after diagnosis.18 The primary predictor of lower mental QOL in one study was distressed mood; primary predictors for lower physical QOL were older age, living alone, FEV1 less than 70% of predicted, distressed mood, time since diagnosis, and more comorbid diseases.9 These factors may help identify survivors at greatest risk for temporary or permanent reductions in mental or physical QOL, paving the way for tailored interventions in defined populations.

Factors Affecting QOL in Lung Cancer Survivors

Treatment-Related Factors

Therapy for early-stage lung cancer includes surgery in most cases, with radiation and chemotherapy also playing an important role in more advanced disease. Late and long-term effects of these therapeutic modalities determine QOL in survivors (Table 1).

Surgery: Surgery substantially reduces HRQOL across almost all dimensions immediately, but HRQOL improves continuously up to 2 years after surgery. Despite improvements, however, nearly 50% of survivors may continue to experience symptoms and functional limitations.19 The type of lung cancer surgery can affect survivor QOL, with lobectomy resulting in increased postoperative dyspnea compared with sublobar resection in the first month after surgery. QOL scores in all domains except pain approximate baseline values 3 months postoperatively in both groups, indicating good recovery. However, after pneumonectomy, physical functioning, pain, shoulder function, and dyspnea do not return to baseline even after 12 months.20 Another study evaluating the impact of surgical modality on QOL concluded that most QOL indicators remained near baseline for up to 24 months after surgery, except physical functioning, pain, and dyspnea, which remained significantly impaired. QOL was significantly better after lobectomy than after pneumonectomy with regard to physical function, social function, role function, global health, and pain.21,22

Mode of surgery may also affect QOL. In a Japanese study comparing QOL in patients undergoing video-assisted thoracoscopic surgery (VATS) versus open thoracotomy for lung cancer, those undergoing VATS procedures had an improved QOL in 6 dimensions (social functioning, role-physical, role-emotional, vitality, bodily pain, and mental health perception) whereas only 2 dimensions improved (bodily pain and mental health perception) over time for patients undergoing thoracotomy. This suggests that recovery in QOL indices may improve faster in patients who undergo VATS procedures than in those who undergo open thoracotomy.23 Further study on the impact of different surgical procedures and potential intervention is necessary to optimize postsurgical QOL.

Adjuvant Chemotherapy: Adjuvant chemotherapy with platinum-based regimens improves survival after surgery, based on data from the JBR.10 study and other trials.2427 However, long-term toxicities of adjuvant cisplatin-based chemotherapy include sensory neuropathy and hearing loss, estimated to occur in approximately 45% and 21% of patients, respectively, in the JBR.10 study.24 In a QOL companion study of JBR.10 participants, global QOL declined in both the observation and chemotherapy arms, with both groups experiencing high symptom burden related to fatigue and postsurgical pain. A higher proportion of patients in the observation arm reported improved QOL in global, physical, role, cognitive, and social functioning domains at 3 months postoperatively

Table 1

Summary of Potential Treatment Strategies for QOL Factors in Lung Cancer Survivors

Table 1
compared with patients in the chemotherapy arm. At 9 months, the global QOL of the patients in the chemotherapy arm was comparable with that of patients in the observation arm, indicating a recovery of QOL for patients treated with chemotherapy. However, for those receiving cisplatin, sensory neuropathy and hearing loss persisted throughout the study follow-up period, up to 30 months posttreatment.21 These results suggest that adjuvant therapy improves survival at a cost of short-term decline in global QOL, which improves to a significant degree when treatment is completed. A retrospective evaluation of long-term HRQOL among patients who underwent surgery for NSCLC suggested that adjuvant therapy may also predict for improved long-term HRQOL at a median follow-up of 4.8 years.15

Radiation Therapy: Radiation therapy also affects QOL in lung cancer survivors. Machtay et al28 assessed the risk of death from intercurrent diseases in survivors who received adjuvant radiation. Advanced age and higher radiotherapy dose predicted for increased risk. Radiation pneumonitis is a well-known complication that can occur up to many years after treatment, with an incidence of 2% to 16%.2932 Symptoms include cough, dyspnea, and, in extreme cases, respiratory failure and death.33 Variables predicting for radiation pneumonitis include pretreatment performance status, female gender, and FEV1.33 Ongoing tobacco use at the initiation of RT may paradoxically be associated with a lower incidence of radiation pneumonitis.32 Treatment for pneumonitis may include steroids and supplemental oxygen, although efficacy has not been studied in a systematic way.34

Physical Symptoms in Lung Cancer Survivors

Long-term physical symptoms that persist after treatment for lung cancer may include respiratory issues, fatigue, hearing loss, neuropathy, and postsurgical pain.35 Respiratory issues can occur in nearly 60% to 70% of the patients and include dyspnea, cough, wheezing, phlegm, decreased functionality, and pain (including postthoracotomy pain).4 Fatigue may develop over time, diminishing energy, mental capacity, and the psychological condition of patients with cancer.36 It is the most common symptom associated with cancer therapy, affecting nearly 70% to 90% of patients.3638 Among lung cancer survivors, the prevalence of fatigue approaches 70% at 4 months after thoracotomy.39 In one study, the prevalence of fatigue was 57%, with 47% of patients reporting mild fatigue and 17% experiencing moderate to severe fatigue leading to significant functional impairment. Pulmonary disease, depression, and anxiety were associated with a higher incidence of fatigue, whereas those who met physical activity guidelines reported less fatigue.35 Some studies suggest resolution of fatigue at 3 to 6 months after lung cancer surgery,16,40 whereas other studies show that fatigue persists for months to years after treatment completion.19,39 Fatigue may also be related to organic disorders, such as thyroid dysfunction, depression, and/or anxiety.35

Pain has been reported to be the most distressing symptom experienced by cancer survivors41,42 throughout the disease and treatment trajectories. Nearly 90% of all patients with cancer experience pain during the course of their illness.43 Results of a study of diverse cancer survivors showed that 20% had cancer-related chronic pain, and 43% had experienced pain since diagnosis. The presence of pain predicts a poorer QOL in several domains, is more frequently experienced by women, and has a considerable impact on QOL among patients with cancer and survivors.44 Chronic pain was reported in 25% long-term NSCLC survivors followed in a survivorship clinic.45 Emerging evidence suggests a potential genetic basis of pain severity, with single nucleotide polymorphisms in PTGS2 and LTA genes being shown to predict pain severity and QOL in long-term NSCLC survivors.46 Additionally, adjuvant chemotherapy with cisplatin-based regimens is also associated with persistent neuropathy and pain that can affect overall QOL in treated patients, even at 30-month follow-up.21

Postthoracotomy pain is a unique problem of NSCLC survivors. It is described as recurring or persistent pain with neuropathic characters (burning, dysesthesia, aching) along the thoracotomy incision, usually persisting for a prolonged period (>2 months) postoperatively, and occurs in the absence of recurrent/metastatic disease.47 It is likely related to surgical intercostal nerve injury, with an estimated incidence of 11% to 80% in NSCLC survivors who underwent surgery.4852 Nearly 30% of patients report continued pain up to 5 years after surgery.49 Early postoperative pain is the single highest predictor of long-term pain.52

Pain has a considerable negative impact on QOL among lung cancer survivors. Treatment for pain, including neuropathic and postthoracotomy pain, has been reviewed elsewhere53 and may include analgesics such as nonsteroidal anti-inflammatory drugs, opioids, certain antidepressants and antiepileptics, physical therapy, and integrative medical techniques. Early referral to pain management services is often recommended, with more invasive methods, such as electrical nerve stimulation, sympathectomy, and long-term neuromodulation with epidural analgesia or spinal cord stimulation, reserved for survivors with moderate to severe refractory pain.54

Psychosocial Issues in Lung Cancer Survivors

Psychological distress is reported in at least 40% of NSCLC survivors, significantly higher than rates seen in survivors of other cancers.55 Psychological distress may be mediated by many things in NSCLC survivors, including fear of recurrence and guilt about their role in the development of their cancer. Unjustified blame and shame can be associated with the diagnosis of lung cancer and its relation to smoking. A significant proportion of patients with lung cancer, particularly those who had stopped smoking years earlier or had never smoked, feel unjustly blamed for their illness.56

Practical aspects of posttreatment life, such as employment and cost of cancer care, may also contribute to distress. Recent studies of survivors of various cancers suggest that a cancer diagnosis forces departures from the workplace in 17% of survivors and significantly increases financial burden or risk of bankruptcy. Lung cancer significantly increases risk of departure from the workforce compared with other cancers, such as colon cancer (odds ratio [OR], 2.8 for stage II disease and 6.1 for stage III disease),57 and lung cancer survivors have the highest decline in employment rates.58 Kim et al59 showed a decline in employment from 69.6% before treatment to 38.7% after treatment in South Korean NSCLC survivors, significantly lower than the rate of decline in healthy volunteers. This trend of decreasing reentry into the workforce after an NSCLC diagnosis can have a huge impact on receipt of appropriate survivorship care, because loss of employment can cut health insurance benefits and lead to poor compliance or lack of access to follow-up care and recommended treatments. Thus, assessment of practical concerns that can increase distress in this population, and interventions directed at addressing these concerns, are important.

Distress has been associated with noncompliance with cancer surveillance screening behaviors in long-term cancer survivors60 and lack of engagement in health behaviors, such as exercise61 and smoking cessation.62 Despite the association with noncompliance, cancer survivors report feeling that their psychosocial needs are not met within the context of their survivorship care.63 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Survivorship recommend screening for anxiety/depression and psychosocial distress as a part of routine survivorship care (to view the most recent version of these guidelines, visit NCCN.org).8 Apart from screening, adequate follow-up with appropriate referral and treatment of patient distress is indicated.

Studies have shown a beneficial effect of therapeutic interventions on emotional and functional adjustment and treatment- and disease-related symptoms.64 Therapies chosen to help distressed individuals may range from behavioral interventions such as cognitive-behavioral programs, educational/informational programs, and peer support programs.6567 Physical exercise may also help to decrease anxiety and depression, whereas pharmacologic interventions or referral to a psycho-oncologist or other mental health professional may be appropriate.68 At this time, no specific approach appears to be most effective.69 Regular assessment of practical and financial concerns is also key to ensuring that all psychosocial needs are met.

Role of Preventive Health: Lifestyle Factors and Risk of Second Malignancy

Smoking and Lung Cancer Survivorship

Cigarette smoking is the major risk factor for lung cancer development and approximately 80% of lung cancers occur in smokers.70 A diagnosis of lung cancer can serve as a teachable moment for patients, because smoking cessation is known to improve survival71,72 and reduce the risk of recurrence73 in NSCLC survivors. Smoking cessation also increases performance status and QOL.7476 Studies have also shown that patients who continue to smoke in the perioperative period have higher postoperative pulmonary morbidity and mortality.77

Approximately 50% to 80% of smokers quit at the time of lung cancer diagnosis or during the first year,70,78,79 but many return to their habit after several months have elapsed.8082 Lack of emotional support, peer smoking behavior, and psychosocial and/or socioeconomic factors, such as low income, low education, or reliance on government-subsidized health insurance,80,81,8387 have been associated with continued smoking. The presence of comorbidities has been shown to facilitate successful smoking cessation efforts.78,84 Unfortunately, only a small fraction of survivors report having received assistance with smoking cessation, and only 25% of those who continue to smoke indicate that they were given any guidance about smoking cessation from their health care providers.70

Realizing that recommendations from health care providers have a powerful impact on patient behavior,88 a growing proportion of survivors could derive benefits from provider-driven recommendations and interventions designed to promote smoking cessation. In fact, the NCCN Guidelines for NSCLC89 recommend counseling about smoking cessation for all lung cancer survivors as part of routine survivorship care, and both NCCN90 and ASCO91 have recently published guidelines or provider tools to help health care providers assist survivors in their smoking cessation progress. Various methods to facilitate cessation may range from counseling to pharmacotherapy. Current US Public Health Service Clinical Practice guidelines for smoking cessation recommend using the 5A's (Ask, Advise, Assess, Assist, and Arrange) and recommend combination therapy involving behavioral and pharmacologic interventions, because this has been shown to be more effective than any component alone.92 FDA-approved medications include nicotine replacement, sustained-release bupropion, and varenicline. National hotlines and community-based programs are also important resources for survivors interested in smoking cessation.

Physical Activity in Lung Cancer Survivors

All forms of lung cancer therapies lead to varying degrees of physical or functional impairments that can dramatically reduce a patient's ability to tolerate exercise.93 Peak oxygen consumption per unit time (Vo2) is markedly reduced among patients with lung cancer at baseline, and lung cancer surgery is associated with further reductions.94,95 Low baseline exercise capacity among patients with lung cancer is associated with a longer postoperative hospital stay.96 Restriction in physical activity is a well-recognized short-term side effect of lung cancer surgery. Some studies suggest that most patients undergo significant recovery within the first year,16,97,98 whereas others suggest that these deficits may persist.99 Engagement in moderate to strenuous physical activity is lowest in the 6 months after treatment, but thereafter returns to prediagnosis levels or increases.100 Physical activity has been associated with improvements in QOL, fatigue, and functional capacity in various groups of cancer survivors.101 Pulmonary rehabilitation programs for postoperative patients with lung cancer have found positive effects on functional ability, exercise capacity, and dyspnea.102,103 Progressive resistance exercise training (PRET) also has been shown to be a feasible exercise regimen in lung cancer survivors.104 In a study of long-term NSCLC survivors, greater motivational readiness for physical activity was associated with improved QOL.105 Although nearly 66% of survivors do not meet national physical activity guidelines, those meeting the guidelines report better QOL in multiple domains compared with less-active individuals.100,106

Limited data are available to provide exercise guidelines specific for lung cancer survivors. Emerging evidence suggests that routine exercise is associated with improvements in cardiorespiratory fitness, QOL, and fatigue after a diagnosis of early-stage lung cancer.101103,105 The benefits of physical activity and exercise are further strengthened by results of landmark observational studies reporting that regular physical activity (3–5 d/wk for 30 minutes per session, achieving 50%–70% of heart rate reserve) is associated with a reduction in cancer-specific mortality and all-cause mortality in early-stage breast,107,108 prostate,109 and colorectal cancers,110,111 relative to physical inactivity. Thus, it is reasonable to recommend routine physical activity or exercise in NSCLC survivors who can tolerate it.

Although patients who undergo more extensive pulmonary surgeries may be considered at higher risk for exercise-related injuries, general recommendations for routine physical activity and the avoidance of a sedentary lifestyle should be universal. Those with high levels of pulmonary compromise should be referred to trained rehabilitation or exercise specialists.8 Survivors of early-stage lung cancer with less-extensive pulmonary resections should be counseled on the standard guidelines endorsed by the American Cancer Society, NCCN, and American College of Sports Medicine,8,112,113 and should consider working with a trained rehabilitation or exercise specialist if embarking on a new program of physical activity. Guideline recommendations include participating in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity activity each week, preferably distributed throughout the week. Additionally, 2 or 3 weekly resistance or strength training sessions involving major muscle groups should be encouraged. Stretching of major muscle groups should be performed on the day of exercise.8

Risk of Second Primary Malignancies

Curative surgery for lung cancer does not eliminate the risk of developing a recurrence or a new primary lung cancer. In a population-based study, the overall incidence of recurrence was estimated at 27% (local or regional, 7%; systemic, 20%) and was not influenced by histologic type.114 In addition, survivors treated with curative intent develop second primary pulmonary neoplasms at a rate of 1% to 2% per patient-year, and the 5-year survival rate of a second primary lung cancer is approximately 30%.115

Extrapulmonary second primary tumors are also common in lung cancer survivors, occurring in between 3.5% and 8.7% of patients, with an average incidence of 1.8% per patient-year of follow-up.114,116119 These cancers typically occur more than 5 years after the NSCLC diagnosis. There is a predominance of tobacco-related cancers (eg, upper aerodigestive tract, bladder, pancreas) given the shared risk factor of smoking.118 This suggests the importance of surveillance for lung cancer, age-appropriate cancer screening, and efforts toward smoking cessation in lung cancer survivors. NCCN recommends surveillance for recurrent and new primary lung cancer in all individuals who have been treated for early-stage lung cancer, including a history and physical examination and a CT scan of the chest every 6 to 12 months for the first 2 years and then annually to evaluate for second primary lung cancers.89 In light of increased radiation risks from repeated imaging in long-term NSCLC survivors and the encouraging results of low-dose CT screening for lung cancer in high-risk individuals, use of this modality for surveillance in the specific population of long-term NSCLC survivors is being increasingly considered. The American Association of Thoracic Surgeons endorses low-dose CT surveillance beginning in the fifth year after diagnosis, but this recommendation has not been uniformly endorsed by other national guideline panels.2,120,121 Further research evaluating optional surveillance strategies is needed to help delineate the best surveillance imaging technology for this unique high-risk population. Because tobacco use is a risk factor for the development of several malignancies, all age-appropriate cancer screening guidelines should be followed in the care of NSCLC survivors.

Immunizations in Lung Cancer Survivors

Patients with cancer have similar or higher risk of infection with vaccine-preventable diseases compared with healthy adults, including increased risk of morbidity and mortality associated with measles and varicella infections.122 In addition, survivors undergoing lung resections may be at higher risk for morbidity in the setting of pneumococcal or influenza infections. In 2009, among adult cancer survivors, only 57.8% reported receiving an influenza vaccination and 48.3% reported receiving pneumococcal vaccination.123 Certain live virus vaccines are contraindicated in actively immunosuppressed patients, and NCCN recommends holding such vaccines during the 4 weeks preceding chemotherapy and at least 3 months after completing therapy. Influenza, pneumococcal, tetanus, and diphtheria vaccines are recommended per NCCN Guidelines for NSCLC89 and Survivorship.8

Conclusions

In summary, lung cancer survivors experience impairment in physical functioning, mental health, and overall HRQOL that can be attributed to their cancer, its treatment, and comorbidities. Physical and pulmonary rehabilitation and management of psychological distress help promote HRQOL outcomes in survivors and have the potential to improve QOL to pretreatment levels. Efforts to formulate a comprehensive survivorship care plan addressing the major issues that surround long-term NSCLC survivors are key to ensuring comprehensive care. Future collaborative efforts are needed to elucidate the complex issues that affect HRQOL in NSCLC survivors and to understand which interventions will provide beneficial impact. Now is the time to conduct additional research in this increasing population and to develop interventions based on current understanding of the needs and issues they face.

Dr. Vijayvergia has disclosed that she has no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors. Dr. Shah has disclosed that his spouse is employed by Roche Diagnostics. Dr. Denlinger has disclosed that she receives editorial/writing support from Pfizer Inc., and scientific advisory honorarium and research support from Eli Lilly.

EDITOR

Kerrin M. Green, MA, Assistant Managing Editor, JNCCN—Journal of the National Comprehensive Cancer Network

Ms. Green has disclosed that she has no relevant financial relationships.

CE AUTHORS

Deborah J. Moonan, RN, BSN, Director, Continuing Education, has disclosed that she has no relevant financial relationships.

Ann Gianola, MA, Manager, Continuing Education Accreditation & Program Operations, has disclosed that she has no relevant financial relationships.

Kristina M. Gregory, RN, MSN, OCN, Vice President, Clinical Information Operations, has disclosed that she has no relevant financial relationships.

Rashmi Kumar, PhD, Senior Manager, Clinical Content, has disclosed that she has no relevant financial relationships.

Deborah Freedman-Cass, PhD, Oncology Scientist/Senior Medical Writer, has disclosed that she has no relevant financial relationships.

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Correspondence: Crystal S. Denlinger, MD, Department of Medical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111. E-mail: crystal.denlinger@fccc.edu

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