Challenge For Cancer Survivorship: Improving Care Through ...

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Aug 23, 2017 - themselves in the term “survivor,” mostly because they perceive it as a label and would rather consider cancer as one of the many life.
JOURNAL OF CLINICAL ONCOLOGY

Challenge For Cancer Survivorship: Improving Care Through Categorization by Risk TO THE EDITOR: The recent article in Journal of Clinical Oncology titled “Going Beyond Being Lost in Transition: A Decade of Progress in Cancer Survivorship” by Nekhlyudov et al1 is a remarkable overview of the development and progress of survivorship care—a distinct phase along the cancer continuum that has now gained full recognition worldwide. Leading us through the major achievements in cancer survivorship, the authors state: “As we acknowledge the end of 2016, we marvel at the progress that has been made over the past decade and the two preceding decades of cancer survivorship advocacy.” Although significant success is certainly true for advocacy, it may be best to limit any celebration regarding the success of the medical management and care delivery aspects of survivorship care. Too many of those whom we proudly define as long-term survivors suffer from serious sequelae (physical and psychological) of their primary cancer and its treatments and remain at risk for late relapses and second primary cancers. In addition, many patients worldwide, including in the United States, do not recognize themselves in the term “survivor,” mostly because they perceive it as a label and would rather consider cancer as one of the many life events that contributed to shape their identity, rather than defining it.2 As the authors acknowledge, many issues remain unsolved, such as what may constitute the best survivorship care model or the most appropriate follow-up guidelines for different cancer types and stages.1 Furthermore, the unique individual and sociocultural factors that play a major role in the delivery and acceptance of survivorship care are yet to be fully addressed.1,3 The cancer journey is and remains hard for most patients, and the key question, according to the authors is: “What will the next decade achieve?”1 As always in science and medicine, the answer to this question depends on the priorities that survivorship care professionals and cancer survivors jointly set for themselves.4 We believe that one critically important priority is categorization (stratification) of survivors according to risk.5 Proper categorization will allow survivorship care to be tailored to individuals by making distinctions about recurrence and late effects. For example, we can define an individual patient as cured of his or her primary cancer according to strict criteria (including statistical ones), where “cured” refers to a population of long-term cancer survivors whose risk of mortality is no greater than that of the general age- and sex-matched population. According to the Italian Association of Cancer Registries (AIRTUM), prevalence data indicate that a certain portion of patients diagnosed with different cancers will never suffer from relapse of their primary cancer.6 Despite this epidemiologic evidence, heated debate surrounds this issue, and many oncologists are still reluctant to ever use the word “cured” for their patients.7

C O R R E S P O N D E N C E

In referring to Recommendation 3 of the 2006 Institute of Medicine Report,8 the authors write: “As personalized medicine evolves, late effects may be a thing of the past, especially if we can define personal host factors that render some individuals at greater risk of the most troublesome late effects, and guidelines will instead focus on individuals’ risks and benefits from specific treatments.”1 Although it may be too optimistic a hope that “late effects may be a thing of the past,” we agree with the application of a personalized approach to survivorship care, first and foremost through the definition and application of categories that match services with need. This categorization can facilitate tailored risk-based survivorship care; dissemination of effective clinical and organizational approaches; evidence-based health professionals’ and survivors’ education; effective communication with patients, survivors, and their families; and efficient follow-up through surveillance recommendations and guidelines. The value of Mullan’s initial definition of cancer survivor9 and its National Coalition of Cancer Survivorship extension to family members and loved ones as all persons touched by cancer10 is undeniable, because it recognizes the tremendous impact of a cancer diagnosis on both patients and their families, which persists over time regardless of the medical outcome. To improve the survival and quality of life of our current and future patients with cancer, the authors conclude: “We must strive to coordinate care, using a risk-stratified approach that not only focuses on cancer-related effects, but also on comorbid medical conditions and socioeconomic disparities.”1 We agree with the authors and further submit that categorization of cancer survivors, on the basis of these factors along with an ongoing effort to improve risk-assessment tools,5 will contribute to improving the cancer journey for our patients and families through the various seasons of survival.

Paolo Tralongo Umberto I Hospital, Siracusa, Italy

Mary S. McCabe Consultant in Survivorship and Bioethics, Arlington, VA

Antonella Surbone New York University Medical School, New York, NY

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Disclosures provided by the authors are available with this article at jco.org. REFERENCES 1. Nekhlyudov L, Ganz PA, Arora NK, et al: Going beyond being lost in transition: A decade of progress in cancer survivorship. J Clin Oncol 35:1978-1981, 2017 2. Smith KC, Klassen AC, Coa KI, et al: The salience of cancer and the “survivor” identity for people who have completed acute cancer treatment: A qualitative study. J Cancer Surviv 10:457-466, 2016 3. Surbone A, Halpern MT: Unequal cancer survivorship care: Addressing cultural and sociodemographic disparities in the clinic. Support Care Cancer 24: 4831-4833, 2016

© 2017 by American Society of Clinical Oncology

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Corresponding author: Antonella Surbone, MD, PhD, Department of Medicine, New York University Medical School, Division of Hematology and Medical Oncology, 550 First Ave, BCD 556, New York, NY 10016; e-mail: [email protected]. Downloaded from ascopubs.org by 94.95.83.94 on October 13, 2017 from 094.095.083.094 Copyright © 2017 American Society of Clinical Oncology. All rights reserved.

Correspondence

4. McCabe MS, Bhatia S, Oeffinger KC, et al: American Society of Clinical Oncology statement: Achieving high-quality cancer survivorship care. J Clin Oncol 31:631-640, 2013 5. Surbone A, Tralongo P: Categorization of cancer survivors: Why we need it. J Clin Oncol 34:3372-3374, 2016 6. Dal Maso L, Guzzinati S, Buzzoni C, et al: Long-term survival, prevalence, and cure of cancer: A population-based estimation for 818 902 Italian patients and 26 cancer types. Ann Oncol 25:2251-2260, 2014 7. Tralongo P, Dal Maso L, Surbone A, et al: Use of the word “cured” for cancer patients—Implications for patients and physicians: The Siracusa charter. Curr Oncol 22:e38-e40, 2015

8. Hewitt M, Greenfield S, Stovall E. From Cancer Patient to Cancer Survivor: Lost in Transition. Institute of Medicine and National Research Council. Washington, DC, National Academies Press, 2006 9. Mullan F: Seasons of survival: Reflections of a physician with cancer. N Engl J Med 313:270-273, 1985 10. National Coalition for Cancer Survivors: Defining Cancer Survivorship. http:// www.canceradvocacy.org/news/defining-cancer-survivorship/

DOI: https://doi.org/10.1200/JCO.2017.74.3450; published at jco.org on August 23, 2017.

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© 2017 by American Society of Clinical Oncology

Downloaded from ascopubs.org by 94.95.83.94 on October 13, 2017 from 094.095.083.094 Copyright © 2017 American Society of Clinical Oncology. All rights reserved.

JOURNAL OF CLINICAL ONCOLOGY

Correspondence

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Challenge For Cancer Survivorship: Improving Care Through Categorization by Risk The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I 5 Immediate Family Member, Inst 5 My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc. Paolo Tralongo No relationship to disclose

Antonella Surbone No relationship to disclose

Mary S. McCabe No relationship to disclose

jco.org

© 2017 by American Society of Clinical Oncology

Downloaded from ascopubs.org by 94.95.83.94 on October 13, 2017 from 094.095.083.094 Copyright © 2017 American Society of Clinical Oncology. All rights reserved.