Crystal S. Denlinger
Crystal Denlinger and Terry S. Langbaum
For most cancers, intensive posttreatment surveillance does not improve survival, but can induce anxiety in patients and may lead to unnecessary testing due to false-positive results. For colorectal cancer, more intensive surveillance, especially during the first few survivorship years, is warranted. For breast cancer, surveillance for second primary cancers with annual mammography is warranted. This may also be the case for non-small cell lung cancer. For other tumors, less routine surveillance testing can be recommended.
Crystal S. Denlinger and Jennifer Ligibel
Jennifer A. Ligibel and Crystal S. Denlinger
Survivorship is a stage in the cancer journey like diagnosis and treatment, but it tends to be somewhat neglected in the quiet afterthoughts of treatment completion. Although cancer recurrence, second cancers, and late side effects of treatment are major concerns for survivors, survivors also may experience a variety of long-term physical and psychological sequelae of a cancer diagnosis and treatment. Oncology professionals may be ill-prepared to tackle these topics, and they have few guidelines for meeting these patient needs. In this article, Dr. Jennifer A. Ligibel and Dr. Crystal S. Denlinger present highlights from the inaugural NCCN Clinical Practice Guidelines in Oncology on survivorship care, focusing on the subtopics of exercise, cognitive function, immunization, and sexual function. They also discuss implementing new recommendations on survivorship assessment in the clinic.
Namrata Vijayvergia, Prashant C. Shah and Crystal S. Denlinger
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.
Efrat Dotan, Ilene Browner, Arti Hurria and Crystal Denlinger
Most patients with colon cancer are older than 65 years. Their treatment poses multiple challenges, because they may have age-related comorbidities, polypharmacy, and physical or physiologic changes associated with older age. These challenges include limited data on the ability to predict tolerance to anticancer therapy and the appropriate use of treatment modalities in the setting of comorbidity and concurrent frailty. The low number of older patients enrolled in large clinical trials results in a paucity of evidence to guide oncologists in the appropriate management of this population. In early-stage disease, clinical dilemmas arise regarding the ability of older patients to undergo successful curative surgical procedures and the risk/benefit ratio of adjuvant chemotherapy. The management of metastatic disease raises questions regarding the clinical benefit of various anticancer therapies and the role of combination therapy with possible increased toxicity in the noncurative setting. Overall, the available evidence shows that fit older patients are able to tolerate treatment and derive similar clinical benefits to younger patients. Limited data are available to guide treatment for less-fit, more-vulnerable older patients. This lack of data leads to variations in treatment patterns in older adults, making them less likely to receive standard therapies. This review provides an overview of the available data regarding the management of older adults with colon cancer in the adjuvant and metastatic settings.
Mary Ann Morgan and Crystal S. Denlinger
The number of cancer survivors will be increasing over the next decade. Caring for this burgeoning population will place demands on oncologists and primary care providers to meet the needs of the expected large numbers of new patients as the baby-boom generation ages. Many will live beyond 5 years and possibly for decades after diagnosis. Patients experience many transitions depending on the type and stage of cancer, its treatment, and the long-term or late effects they have from the disease and its treatment. The Institute of Medicine’s report, “From Cancer Patient to Cancer Survivor: Lost in Transition,” recommends that patients be provided with a summary of their cancer treatment and follow-up care plan (ie, survivorship care plan [SCP]), including recommendations on healthy lifestyle behaviors and resources to promote self-care. This plan should be shared with the patient’s other health care providers, including the primary care provider. This will facilitate communication among providers and with the patient, which is a key component to quality care. The American College of Surgeons Commission on Cancer has also made providing SCPs to patients at completion of treatment a quality standard. Barriers to providing SCPs have been identified and include lack of time, reimbursement, and knowledge of late treatment effects and current guidelines. Survivorship guidelines are being developed by professional organizations that may be useful for providers. This article provides some practical tools that address these recommendations to help providers and patients with transitions along the cancer trajectory.
Crystal S. Denlinger and Andrea M. Barsevick
Edited by Kerrin G. Robinson
With advances in treatment, colorectal cancer (CRC) is being transformed from a deadly disease into an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. Research has shown that physical and mental quality of life for CRC survivors was inferior compared with age-matched individuals without cancer. Although issues and symptoms were most prominent during the first 3 years, long-term effects of treatment can persist and include fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. The unique challenges and issues of CRC survivors can and should be addressed by health care providers and the research community to ensure effective interventions and models of care to manage these problems. This article discusses what is known about the long-term effects of CRC treatment on quality of life, the care of survivors, and existing models of survivorship care.
Gabrielle Gauvin, Leigh Selesner, Marcin Chwistek, Molly Collins, Crystal Denlinger, Mark Itzen, LCSW, Kenneth Patrick and Jeffrey Farma
Background: Malignant bowel obstruction (MBO) is a frequent presentation of advanced abdominal malignancy. Despite the frequency of MBO and the availability of NCCN Guidelines for its management, clinicians struggle to create a personalized care plan accounting for a patient’s current condition, prognosis, and goals of care. The aim of this project is to develop a discussion tool to implement on admission to ensure realistic prognostication and appropriate involvement of the patient, caregivers, and multidisciplinary team in treatment decisions. Methods: At our tertiary care center, a multidisciplinary team composed of surgical oncologists, medical oncologists, palliative care specialists, hospitalists, social workers, and nutritionists developed an algorithm to implement when a patient is admitted with MBO. The algorithm was influenced by the NCCN Guidelines for palliative care but was designed as a single-page checklist that could be easily executed by all team members. Results: The MBO admission checklist is divided into 4 sections. The general assessment section includes information about the etiology, severity, and reversibility of the current and past MBO. Also, the patient’s resuscitation and functional status are reviewed. The cancer care coordination/communication section covers the patient’s oncological history and estimated lifespan, as well as the need for further coordination of care and a goals of care discussion. The subsequent portion covers the management plan, with specific decisions resulting from a goals of care discussion as well as the need for specialized consults. The medical, procedural, and operative interventions the team and patient discussed as options are also documented. A key portion is the risks and benefits discussion for each treatment modality. Lastly, the discussion about future considerations section explores the patient’s wishes for the next episode of MBO. Conclusions: The goal of this checklist is to ensure that a comprehensive discussion is held between the different services involved in a patient’s care at every admission for MBO in order to provide a personalized management plan and improve communication. The next step in our study is to assess the effectiveness of implementation of the checklist as well as its impact on patient satisfaction, quality of life, early hospice referral, and outcomes.