How do cancer patients live long and well? 3 "The Lancet" focuses on the best model of cancer care!

▎ WuXi AppTec content team editor

With the popularization and promotion of early diagnosis and early screening and the continuous improvement of cancer diagnosis and treatment technology, the overall 5-year survival rate of cancer patients has increased significantly in recent years, and more and more cancer patients are expected to achieve clinical cure or long-term survival. In the context of the current aging population, cancer survivors have gradually become a huge group, so the long-term health management of cancer survivors has also received more and more attention.

Recently, The Lancet published a series of 3 special articles, which systematically elaborated on the clinical common problems of cancer survivors, the exploration of the best care model, and the long-term care of children/adolescent patients. This topic has also received popular recommendations from the homepage of the Lancet's official website.

The feature article points out that the current model of care led by clinical oncologists cannot adequately address the needs of cancer survivors, including physical, psychological and supportive care. In the future, the exploration of individualized care models for survivors of different types of cancer is expected to make these patients live longer and live better!

Screenshot source: THE LANCET

Long-term care goals for cancer patients

The paper states that there are 4 main goals for the care of cancer survivors:

Prevention of tumor recurrence, the emergence of new lesions and other later effects of diseases;

Monitor possible spreading, recurrent, or secondary tumours and assess the later physical and psychosocial effects of disease treatment on patients;

Interventions in the disease and the impact of the course of treatment on patients;

Clinical specialists and primary caregivers work together to ensure that the health needs of all cancer survivors are met.

Although the number of international studies on cancer survival has increased significantly over the past 15 years, there is still room for significant improvement in cancer survival care in several areas, mainly involving:

Multiple common types of cancer other than breast cancer;

Cancer survival patients over the age of 65;

Patients with long-term survival (confirmed for more than 5 years);

The long-term effects of novel therapies on patients;

Biological mechanisms and genetic factors associated with cancer recurrence and adverse reactions;

Interventional studies in adolescent and young adult survival patients (i.e., 18 to 40 years);

Model and quality of care for cancer survivors.

In-depth research into these key issues will help establish more scientific models of care in the future, thereby reducing the unmet needs of cancer survivors and improving their overall quality of life.

Management of common side effects

At least two-thirds of cancer survivors currently have physical, psychological, health education, and nursing needs that are not well identified or well managed under the current care model. In addition, the results of systematic evaluation showed that cancer survivors have a wide range of problems such as pain, fatigue, sleep disturbances, fear of cancer recurrence, confusion about the future, and lack of awareness of how to improve their sense of well-being.

Cardiac insufficiency

Cardiac insufficiency is more common in patients with breast cancer, sarcoma, and hematological tumor survival. Among them, 0.14% to 48% were caused by anthracycline treatment, and 7% to 28% were caused by high-dose cyclophosphamide therapy. In addition, patients receiving regional radiotherapy (radiation dose ≥ 30 Gy) had a 10-fold and 2.8- to 4.7-fold increased risk of developing cardiac insufficiency.

For cancer survivors with cardiac insufficiency, the recommended management is to monitor cardiac function by regularly evaluating cardiovascular risk factors. Current european Society of Oncology (ESMO) guidelines recommend echocardiography in patients at the 6th, 12th, and even 2nd year after treatment, while the American Society of Clinical Oncology (ASCO) guidelines recommend echocardiography if a patient develops signs or symptoms of cardiac dysfunction.

On this basis, patients may choose cardiology referral, optimization of cardiovascular risk factors, or management of cardiac insufficiency through heart failure treatment (e.g., with drugs such as ACE inhibitors, angiotensin receptor blockers, and β blockers).

Metabolic syndrome

Metabolic syndrome caused by cancer treatment is about 8% to 39% of cancer survivors, and mostly occurs in multiple childhood malignancies, breast cancer, colorectal cancer, testicular cancer, hematological tumors, nerve tumors, prostate cancers, gynecological tumors, and thyroid cancers.

For such symptoms, we can manage them through lifestyle interventions (e.g., physical activity, healthy eating, smoking cessation) or standard interventions for concomitant diseases (e.g., hypertension, hyperlipidemia, and diabetes).

Lymphedema

Lymphedema is more common in patients with breast, head and neck tumors, prostate cancer, bladder cancer, gynecological tumors, and melanoma, and its incidence is about 5% to 75%, and varies according to the population of patients studied. For cancer survivors with lymphedema, lymphedema can be eliminated by manual lymphatic drainage, compression therapy, or moderate exercise.

pain

Cancer-related pain can occur in all types of cancer. Meta-analyses of 122 studies showed that 38% of cancer patients experienced moderate to severe pain; during disease treatment (55%) and patients with advanced disease (66.4%) were most likely to experience cancer-related pain.

For cancer-related pain, non-pharmacological treatments include exercise, acupuncture, and psychological methods (e.g., mindfulness-based psychological interventions, meditation, and supportive group therapy); pharmacological treatments include nonsteroidal anti-inflammatory drugs, acetaminophen, adjunctive analgesics, antidepressants and anticonvulsants, opioids, and cannabinoids.

Peripheral neuropathy

Chemotherapy-induced peripheral neuropathy is most common in breast, prostate, colorectal, gynecological, and head and neck tumors. Depending on the time after chemotherapy, the incidence ranged from 30% to 68.1%. Chronic as well as painful peripheral neuropathy can be treated with duloxetine, and patients may also derive potential benefits from exercise and acupuncture.

Bone health

Patients with breast cancer, prostate cancer and hematological tumors are more likely to have bone problems, such as bone loss, osteoporosis, fractures, etc., and the probability of occurrence is related to the patient's own age and treatment drugs. For cancer survivors who may have bone problems, adequate calcium and vitamin D supplementation is currently recommended for their daily diet, in addition to quitting smoking and maintaining moderate exercise. These patients can also be treated with bisphosphonate drugs based on bone density testing.

Immune-related adverse reactions

Patients treated with immune checkpoint inhibitors may develop immune-related adverse effects such as colitis, pititis, thyroid dysfunction, and rashes. Immune-related adverse reactions are more common in melanoma, lung cancer, kidney cancer, and bladder cancer. Depending on the therapeutic drug and clinical trial, the incidence ranges from 15% to 90%. Among them, 13% of severe cases of immune-related adverse reactions require discontinuation.

Clinicians need to identify immune-related adverse effects from immune checkpoint inhibitor therapy in a timely manner and grade the severity. On this basis, patients can receive immunosuppressive therapy and adjust the original immunotherapy regimen for treatment.

Management of childhood and adolescent cancer patients

The paper notes that the incidence of childhood and adolescent cancer has been slowly rising over the past few decades. In 2020, about 300,000 people aged 19 and under were diagnosed with cancer worldwide.

With the continuous advancement of treatment methods and clinical care, the prognosis of childhood and adolescent cancer patients worldwide has improved significantly, and the survival time of these patients has also been significantly extended, even reaching more than 60 years. But anti-cancer treatments are likely to cause irreversible damage to the developing organ systems of children and adolescents.

As a result, as follow-up increases, the risk of developing later health problems increases, although the risk of disease recurrence in childhood and adolescent cancer patients decreases. It is worth noting that due to the obvious knowledge gap between this group of cancer survivors and medical caregivers, and the medical care received by this part of the population may be scattered during their growth, there are also huge challenges in the care of childhood and adolescent cancer patients.

Long-term risk factors after treatment in childhood and adolescent cancer survivors (Image source: Reference [3])

The paper emphasizes that childhood and adolescent cancer survivors may need to face a range of side effects that may occur later in treatment, the most common of which include cardiovascular disease, endocrine abnormalities, and secondary malignancies. In addition, anti-cancer treatment may also cause lung, kidney, fertility, psychological, cognitive and other health barriers for children and adolescent cancer patients. How to better collaborate to transition their care from childhood to adulthood is an important challenge.

Exploration of care models for cancer patients

The paper notes that the number of cancer survivors is increasing dramatically, but current care models are unable to address many of the unmet needs of cancer survivors. At present, scientists have carried out a large number of experiments to explore alternative nursing models in depth, such as the nursing model led by primary caregivers, the nursing model in which clinical oncology experts and primary nursing staff collaborate, and the nursing model led by oncology nurses.

The exploration of these alternative models may lead to important ideas for more efficient care. In the future, we may be able to choose the most appropriate individualized care measures for patients based on their different characteristics (e.g., risk of long-term side effects, risk of late-onset side effects, individual needs, and different self-management capabilities of patients).