Today's Practice: Changing the Business of Medicine National Edition Q1 2018 | Page 44

P RA CT I CE MA NA GE ME NT
Cancer Survivorship
An individual is considered a cancer survivor from
the time of diagnosis through the balance of his or
her remaining life. Coordination of care between
primary care providers and specialists is of most
importance and focus should be on developing a
survivorship care plan which includes educating
survivors about their follow-up schedules and com-
munication with other care providers on manage-
ment. The current article focuses on care of survivors
after completion of cancer treatment and typically in
clinical remission.
General Assessment
Cancer survivors should be periodically assessed to
determine any necessary intervention and needs at
least on an annual basis by either their primary care
providers or oncologists. These assessments are
directed mainly to determine whether the possible or
contributing cause for symptoms like disease status,
functional
status,
medications
(including
over-the-counter and supplements), comorbidities,
review of prior cancer treatments, family history and
psychosocial factors. Special detail should be focused
on anxiety, depression and distress experienced by
cancer survivors. Pertinent issues are addressed in
more detail below.
Cardiac Toxicity
Cardiac toxicity is particularly seen in patients who
receive anthracycline based chemotherapy regimen.
In addition, breast cancer patients who receive Her-2
directed therapy are at higher risk. Anthracycline
induced heart failure can take years or even decades
to manifest. Her-2 directed therapies can cause
cardiac dysfunction even early on. The risk for cardi-
ovascular problems depends on type of anthracycline
use and cumulative dose received. 2D Echo should
be done in cancer survivors who have one or more
cardiac risk factors within one year after completion
of anthracycline therapy and subsequently as guided
by clinical course.
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Manpreet Chadha, MD
Psychosocial side effects
Cancer survivors commonly experienced distress
which is defined as a multifactorial, unpleasant,
emotional experience of a psychological, social,
and/or spiritual nature which may interfere with
ability to cope effectively with cancer, physical
symptoms and treatment.
Medical treatment should be initiated early on in
patients who require pharmacological and
non-pharmacological interventions. Screening for
substance abuse should be considered in patients
who appear to have drug-dependence and referred
to substance abuse specialist done accordingly.
Referral to psychiatry should be done early on in
care.
Growing evidence supports the validity of
patient-reported cognitive dysfunction. Neuropsy-
chiatric testing and brain imaging can help
provide objective evidence of cognitive dysfunc-
tion following cancer treatment. There is limited
evidence to guide management of this condition.
Depression should be ruled out for cognitive
decline. Cognitive Rehabilitation can include
occupational therapy, speech therapy and
neuropsychology. Use of psychostimulants like
methylphenidate or modafinil should be consid-
ered under specialist guidance.
Fatigue
Fatigue is one of the most common complaints
and individuals undergoing cancer therapy and
can be related to immediate side effect of chemo-
therapy. Moderate fatigue lasting up to one year
can occur in the proportion of cancer survivors
and it is common in patients who have received
chemotherapy and or radiation. Fatigue can be
rated on a scale of 0 to 10 similar to Pain Scale.
Contributing factors like comorbidities , alcohol
and substance abuse, cardiac dysfunction, endo-
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