Preventive Health in Cancer Survivors: What Should We Be Recommending?

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  • a University of Colorado Cancer Center, and Division of General Internal Medicine and Division of Medical Oncology, University of Colorado Denver School of Medicine, Aurora, Colorado.

Individuals with a history of cancer, often referred to as cancer survivors, may experience late and long-term effects of their treatment. Because these individuals live longer in the survivorship phase, some of these late effects may also be considered risk factors for other chronic conditions. With cancer and cardiovascular disease now the top 2 leading causes of death in the United States and with common risk factors for both, as well as the morbidity that can occur after cancer treatment, preventive health is becoming an important issue in cancer survivorship care. Multimorbidity is also becoming increasingly commonplace. Along with an ever-expanding number of guidelines available to help guide care and treatment in the noncancer population comes the need to consider where these guidelines overlap or intersect when considering preventive health recommendations specific to cancer survivors. Counseling for health promotion in survivors is lacking. Many currently available guidelines may not apply to this population, and an evidence base is building to help supplement clinical judgement. An interdisciplinary approach will be necessary to help implement preventive care decision-making early in the survivorship trajectory and to ensure that cancer survivors are receiving consistent messages, and patient preferences and priorities should be taken into account when doing so. Incorporating preventive health into collaborative survivorship care can help maintain a high quality of life for individuals living after a cancer diagnosis.

An increasing number of people are presenting to their healthcare providers (HCPs) with a history of cancer. As of January 2016, there were 15.5 million Americans living with a history of cancer.1 Bluethmann et al2 predict that 26.1 million survivors will be living in 2040 and that 47% will live >10 years after their diagnosis. In 2018, an estimated 1.7 million new cases of cancer will be diagnosed and 609,400 people will die of their disease; however, the overall death rate from cancer has decreased 26% over the past 3 decades, which translates into 2.4 million fewer cancer-related deaths.3

Although these trends speak to the successes in the areas of early detection, screening, and treatment, the phase of cancer care recognized as survivorship4—from the time of diagnosis through the end of life—brings with it emerging and unique challenges for patients, HCPs, and the healthcare system. An individual living in the survivorship phase of cancer not only may need to manage the various potential late and long-term effects of treatment but also may over time need to shift their focus back to primary prevention or management of other medical conditions, which still includes cancer prevention. According to data within the SEER program of cancer registries, of 765,843 incident cancers diagnosed between 2009 and 2013, approximately one-fourth of adults aged ≥65 years and just more than one-tenth of younger adults aged 20 to 64 years were experiencing their second or higher tcancer.5 Most of these new cancers (termed second primary cancers) were diagnosed in different anatomic locations. These cancers randomly developed, resulted from behaviors (ie, smoking), or occurred because of inherited mutations.

It is also worth considering other major causes of morbidity and mortality after a cancer diagnosis. As the leading all-cause of death for both men and women,6 cardiovascular disease (CVD) rises to the top as a major threat to the health of survivors. CVD, known to be the major cause of death for adults in the US general population, is now known to be a leading cause of death in individuals treated for cancer.712 As with cancer, CVD in survivors could be due to common behavioral risk factors, a family history, a late effect of cancer therapies, or a combination thereof. Some late effects may be considered risk factors for noncancer conditions, such as ischemic heart disease or stroke.

Modifiable risk factors, such as lack of physical activity, hypertension, dyslipidemia, obesity, diabetes mellitus, unhealthy dietary habits, and smoking, contribute not only to CVD but also to cancer, and can also impact the course of cancer survivorship. These risk factors are also targets of preventive health counseling, screening, and care. As such, both oncology and primary care teams have important roles in the preventive care of cancer survivors. The aim of this review is to highlight examples of preventive health recommendations for survivors, emphasizing CVD given its prevalence in the US population and in primary care practice, and to stimulate thought regarding how oncology teams can partner with primary care colleagues to ensure preventive care is being appropriately delivered. It is beyond the scope of this review to discuss comprehensive preventive health recommendations for every combination of cancer type, sex, treatment exposure, and comorbid condition, but an overview of considerations is presented.

Defining Preventive Care

The goal of preventive care is to prevent morbidity and mortality in individuals, including both physical and psychosocial. For individuals at risk for or who have been diagnosed with cancer, recent trends in increasing survival rates are encouraging and to some extent attributable to preventive health activities, such as cancer screening, chemoprevention, testing, and behavioral counseling to reduce known risk factors. To leverage the gains made in cancer treatment and survival, we should not limit the concept of preventive care to reducing the incidence of cancer. We now have the means and an evidence base with which to extend the concept of preventive health beyond preventing a cancer diagnosis. In fact, a cancer diagnosis has been described as a “teachable moment” for health promotion.13,14

To review how preventive health could apply to cancer survivors, consider the traditional layers of preventive care: primary, secondary, and tertiary. Primary prevention has the goal of reducing the risk of a condition ever developing; secondary prevention is intended to detect a condition at an asymptomatic or early stage when opportunities for intervention would be favorable; and tertiary prevention then seeks to reduce the severity and complications of a condition. For patients with a history of cancer, all of these conditions still apply, but with the additional layer that an individual's cancer treatment may itself confer a new set of health risks to consider when engaging in preventive health activities. For cancer survivors, then, these levels of preventive care may overlap.14 The potential late and long-term effects of cancer treatment include conditions, such as CVD, for which preventive strategies exist and behavioral risk factors may influence both cancer survival and comorbid conditions.

Risk-Based Care

The concept of risk-based care in cancer is not necessarily a new one,15 but is especially relevant when discussing preventive care for cancer survivors. With the increasing array of cancer treatments available, including newer targeted and immune therapies, important health risks attributable to these treatments should be identified when known, and communicated to both patients and primary care teams.

Multimorbidity

Individuals with multiple chronic medical conditions are becoming the norm in healthcare, and strategies to counsel patients and recommendations from HCPs will need to account for this.8,16 Preexisting comorbid conditions may negatively impact patients' ability to receive curative treatment for a new cancer, and cancer treatment itself can be associated with late effects or worsening of comorbid conditions.17 An analysis of Medicare beneficiaries revealed that 40% of cancer survivors had ≥1 chronic health condition and 15% had ≥2 chronic health conditions.18 Adults with a history of childhood cancer are more likely than their age-matched peers to have significant chronic medical conditions and to develop them at a younger age.1921 The clinical effects of cancer treatment have been postulated to be similar to aging processes occurring at cellular levels, and aging pathways may impact late complications for survivors.22 Research in the area of multimorbidity clinical care is lacking,23 but on a more practical level, some studies have acknowledged that the clinical challenges of caring for individuals with multiple chronic medical conditions are significant both for patients and HCPs.2426 Some of this may be attributable to the fact that most clinical practice guidelines are disease-specific and do not take into consideration other recommendations that may apply to comorbid conditions.25 Likewise, guidelines may not take into account patient preferences, priorities, or available resources. Notably, of the studies mentioned that discuss multimorbidity, none included cancer as a chronic condition.

Counseling for Health Promotion

Although the benefits of lifestyle modification to reduce cancer risk are well-known, counseling for health promotion in cancer survivors does not always occur. Individuals with a history of cancer are not necessarily faring better than their peers without cancer when it comes to meeting current recommendations for healthy behaviors,2730 but cancer survivors do want and appreciate this counseling.31 Receipt of health behavior counseling could vary based on type of HCP seen, cancer type and stage, and patient characteristics. For example, a 2009 survey of colorectal cancer survivors reported that discussions around health promotion and diet were more likely to occur during visits with primary care providers than with oncologists, but for cancer surveillance the converse was true.32 A separate study of colorectal and lung cancer survivors reported that younger and higher-educated survivors were more likely to have received health behavior counseling from any physician in the previous year, and that chances of this happening were also higher in those with comorbidities, such as diabetes or high blood pressure.33 Cancer survivorship care plans could play an important role in emphasizing the need for preventive care.

Guidance for Preventive Health in Cancer Survivors

The combination of increasing survival rates with the identification of late and long-term effects challenges healthcare teams to provide high-value, appropriate care to reduce the overall burden from cancer. Numerous guidelines from well-respected organizations provide recommendations based on randomized controlled trials, nonrandomized control studies, and/or expert consensus opinion that may apply to patients with cancer or to preventive health in general, but only a handful of these focus explicitly on cancer survivorship (supplemental eTable 1, available with this article at JNCCN.org).3441 Primary care guidelines are often population-focused and are intended for use across the lifespan for preventive care; recommendations that do not focus on the cancer continuum may not be familiar to healthcare teams who primarily treat cancer. Oncology guidelines are often individually focused and intended to help guide cancer diagnosis, treatment, and surveillance; treatment regimens and associated late and long-term toxicities may not be familiar to primary care. The complexity of preventive care for cancer survivors calls for collaboration and clear communication between primary care and oncology teams. This involves choosing and applying the most appropriate guidelines for any one individual. However, such communication and collaboration has proven to be a difficult goal to achieve,42 and there is not uniform agreement on who should be providing the bulk of survivorship care.42,43 In a small study of Canadian family physicians and primary health practitioners, breast cancer survivorship guideline recommendations that focused on preventive health were implemented at higher rates than those focusing on other aspects of survivorship care,44 but gaps did exist across the board.

Review of Preventive Recommendations

A detailed description of all late and long-term effects of treatment for all cancer types is beyond the scope of this review. However, it is worthwhile to highlight a few representative conditions, especially those for which the evidence base may intersect with currently available survivorship guidelines. A comprehensive preventive health examination or survivorship visit would be an ideal time to systematically think about how health promotion and screening recommendations might need to be modified (or not) given an individual's cancer history. A survivorship-focused review of systems as one way to systematically identify potentially significant physical late and long-term effects, described by Ganz45 in 2006, is helpful because it is consistent with routine clinical practice. Using a review of systems to also consider targets for preventive health recommendations is similarly a practical way to approach the topic and could provide common ground for primary, oncology, or other healthcare teams (eg, cardiology, endocrinology) caring for survivors. Table 1 includes examples of the additional layer of recommendations that may be applied for an individual with a cancer history when presenting for preventive care; this list should not be considered exhaustive. Due to the limited evidence base for preventive care in survivors, the best health promotion strategy may be to apply general preventive health recommendations and to have a lowered index of suspicion for a target condition to enable earlier diagnosis.

CVD and CVD Risk Factors: Example of Hypertension

Of the systems to consider in applying preventive health recommendations, the one for which there is perhaps the greatest potential to impact overall morbidity and mortality for cancer survivors is CVD and its associated risk factors. NCCN and the Children's Oncology Group (COG) have guidelines that address anthracycline-induced cardiac toxicity (NCCN,36 COG) and other CVDs (COG).35 The American Heart Association (AHA) recently released a scientific statement on the intersection of breast cancer and CVD46 that emphasizes the importance of assessing CVD risk early in the survivorship phase.

Individuals who have received potentially cardiotoxic cancer therapies may be considered to be at high risk for heart failure and could even be considered

Table 1.

Preventive Care and Additional Considerations for Individuals With a History of Cancer

Table 1.Table 1.
to have asymptomatic heart failure.47 Use of specific agents to prevent the development of cardiomyopathy related to cancer treatment is mixed,48 with some evidence supporting the use of dexrazoxane and potentially β-blockers. Once treatment is completed, scant evidence supports the use of any agent specifically to reduce the risk of CVD in survivors, with AHA recommending following currently available population-based recommendations for the primary prevention of CVD.46

The key may be to proactively identify CVD risk factors and coordinate care in such a way that comorbid risk factors are addressed. Using the example of hypertension as a known risk factor for CVD, the US Preventive Services Task Force (USPSTF) recommends screening adults aged ≥18 years for hypertension.49 This recommendation applies to the general adult population (aged >18 years) with no previous history of hypertension. For this population, recommended intervals are every 3 to 5 years for adults aged 18 to 39 years with normal blood pressure (defined as <130/85 mm/Hg) or yearly for adults aged >40 years. Although there is no mention specifically of cancer survivors, language in the recommendation allows for variance for individuals at “increased risk,” such that those aged <40 years who may have elevated risk should be assessed at yearly intervals.49 This would be an important consideration in adolescent and young adult cancer survivors (aged 15–39 years), for example, who have received cancer treatments or who have experienced sequelae such as weight gain that could increase their risk of CVD but are otherwise asymptomatic, because individuals in this age group may not be aware of the need for this type of screening. Likewise, HCPs of these individuals need to be aware that past cancer treatments may confer additional risk for CVD, and should incorporate strategies to proactively manage these risks while recognizing limitations of currently available guidelines. Again, using the example of hypertension in the primary care setting, recommendations and approaches from other organizations exist and may vary slightly from the USPSTF, such as those from the AHA50 or the American College of Obstetricians and Gynecologists51; the American Academy of Family Physicians endorses the USPSTF recommendations.52 The most recently published guidelines from the Eighth Joint National Committee for the management of hypertension and other conditions state that blood pressure goals may vary depending on patient age and presence of comorbid conditions, such as chronic kidney disease, diabetes, and CVD, but not specifically cancer, although do allow for consideration of those at elevated risk of CVD, which could include those with past cancer treatment.53,54 A more recent meta-analysis of nearly 50,000 participants suggests that using an approach to managing blood pressure based on risk for developing CVD may be more efficient than using numerical thresholds55; this was especially evident for individuals without established CVD or diabetes. Updated guidelines reflect this approach50,56 and address detailed strategies to manage high blood pressure,50 although whether this approach applies to the risk that may be conferred specifically from cancer treatment is unknown. This discussion of the evolving strategy to manage a single risk factor that could also be a late effect of treatment highlights the complexity of providing preventive care recommendations for cancer survivors and is an example of a needed area of collaborative research.

Conclusions

Reducing the overall morbidity and mortality burden related to a cancer diagnosis requires consideration of the associated late and long-term effects of treatment, some of which may be risk factors for disease. Healthcare professionals involved in the diagnosis, treatment, and follow-up for cancer will need to work together across disciplines to implement appropriate recommendations and counseling to achieve this goal. For oncology teams actively involved in cancer treatment or follow-up, this may mean incorporating a dedicated focus on long-term preventive health strategies early in the survivorship phase and outlining risks to long-term health at the time of transition to primary care. For primary care teams, this may mean conceptualizing cancer as a chronic condition and developing familiarity with late and long-term effects of cancer treatment as targets for counseling and prevention. For both, clear communication will be required between these teams and any others involved to avoid unnecessary duplication of efforts or resources, while at the same time ensuring that appropriate recommendations are being applied. Whenever possible, the names of specific guidelines should be used. Interdisciplinary efforts mean that all disciplines (eg, oncology, primary care, cardiology, endocrinology, behavioral health) should be prepared to address each patient's preferences and priorities for care in a consistent way. Because the current evidence base for preventive care in survivors is limited, how preventive care is implemented is as valid a question as what to implement. Taking a good cancer-focused history and assessing for late and long-term effects will go a long way toward filling gaps. The end goal of these efforts is to give a high quality to the extended life that is now possible through advances in treatment.

Dr. Overholser has disclosed that her spouse owns stock in Amgen, Celgene, and GlaxoSmithKline. Dr. Callaway 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.

See JNCCN.org for supplemental online content.

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Correspondence: Linda S. Overholser, MD, MPH, Division of General Internal Medicine, University of Colorado Denver School of Medicine, 12631 East 17th Avenue, Mail Stop B180, Aurora, CO 80045. Email: Linda.overholser@ucdenver.edu

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