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Originally published as JCO Early Release 10.1200/JCO.2005.04.916 on July 25 2005 © 2005 American Society of Clinical Oncology.
A Teachable Moment for Oncologists: Cancer Survivors, 10 Million Strong and Growing!Jonsson Comprehensive Cancer Center at University of California Los Angeles, Los Angeles, CA During the last 25 years we have witnessed the remarkable transformation of cancer from an immediately fatal disease to one in which the majority of individuals receive highly effective treatments that result in long-term, disease-free survivorship.1 One need only think about the remarkable public achievements of cyclist Lance Armstrong to understand that life after cancer can permit continued high levels of physical and psychological performance. Although Armstrong's achievements after cancer may not reflect the norm, they do represent one end of the spectrum for the quality of life after cancer treatment. More often, however, cancer patients are left with subtle and sometimes more overt sequelae from their cancer treatments that follow them into the post-treatment phase of their life after cancer.2-4 These experiences are now well described in a growing body of literature on this topic.5-9 In addition, many individuals live for extended periods of time with cancer as a chronic disease, on long-term therapy with alternating periods of remission and relapse. Although the National Coalition for Cancer Survivorship in 1986 developed a broad definition of cancer survivors to include patients from the time of diagnosis until death (including family members as survivors as well), it is perhaps timely for us to think more specifically about a focused period of time in the cancer trajectory at which patients treated with curative intent have completed their initial cancer therapy and are now post-treatment and in follow-up. It is estimated that there are more than 10 million cancer survivors in the United States today, representing 3.5% of the population.1 It is this growing segment of the cancer-survivor population to which the oncology community now needs to turn its attention in this teachable moment in time. Who are these post-treatment survivors, and why should we be concerned about them? Currently, the 5-year and extended disease-free survival for early-stage breast, prostate, and colorectal cancers exceed 90%,10 and for most survivors of these common adult cancers, death is more likely to occur from competing health problems. Similarly outstanding cancer-survival outcomes are expected for patients diagnosed today with early-stage melanoma; Hodgkin's disease; childhood acute lymphoblastic leukemia; and bladder, uterine, cervical, and testes cancers, as well as a variety of other cancer types. Thus, as oncologists plan cancer treatments for these patients, they must be cognizant of the downstream effects of initial treatment decisions on a whole host of potential late effects2,3; once treatment is completed, the responsibility of the oncologist does not end. As part of a recent survey performed by the American Society of Clinical Oncology (ASCO) Cancer Prevention Committee, a random sample of ASCO members were asked three questions related to the care of cancer survivors. The survey respondents were asked: "To what extent do you provide ongoing general medical care, including health maintenance, screening and preventive services, to the cancer survivors in your practice?"; 31% reported "always," 48% reported "sometimes," 15% reported "rarely," and 5% reported "not at all or do not care for survivors." When asked whether it was the role of the oncology specialist to provide this type of continuing care to cancer survivors, the overwhelming majority (74%) responded "yes." Finally, they were asked whether they were comfortable providing ongoing general medical care to cancer survivors, and 66% responded "yes" (P.A. Ganz, ASCO Cancer Prevention Survey, unpublished data). Thus, although it seems that many of ASCO's members are providing some form of care to cancer survivors, we do not know how focused that care is on surveillance for cancer recurrence versus health promotion, disease prevention, and monitoring or prevention of late effects. In this issue of the Journal of Clinical Oncology, Demark-Wahnefried et al provide JCO readers with a discussion of some of the late physical effects of cancer therapy such as second cancers, osteoporosis, declining physical function, and the metabolic syndrome with its associated health risks.11 In addition, they review the potential for application of health-promotion and disease-prevention interventions in cancer survivors, noting that the diagnosis of cancer itself often represents an event that prompts spontaneous changes in health behaviors among cancer patients and survivors, with significant changes in diet and physical activity reported by many patients.11 However, as also noted by these authors, "[a]lthough a substantial proportion of cancer survivors spontaneously initiate positive behavioral changes, many do not,"11 especially men, those with less education, the elderly, and urban residents. Thus, there is an important and growing need to consider how best to coordinate and foster health-promoting strategies among cancer survivors. As reviewed by Demark-Wahnefried et al,11 there is developing literature on lifestyle interventions among cancer survivors that focus on diet, exercise, tobacco control, and sun protection, for example. However, more research is needed to determine how best to incorporate these interventions into the routine care of cancer patients and survivors, the best timing to initiate such interventions (eg, prevention of weight gain might be considered at the beginning of adjuvant chemotherapy in women with breast cancer), and who among the oncology team or primary care providers will take responsibility for these activities. So, what is a teachable moment, and how does it relate to the context of cancer survivors and health promotion? As noted by McBride et al,12 the phrase "teachable moment" has been used in the behavioral science literature to describe naturally occurring life transitions or health events that have the potential to motivate individuals to spontaneously adopt risk-reducing or health-protective behaviors. A classic example is the middle-aged male smoker with a first myocardial infarction, hospitalized in the coronary care unit, frightened by the seriousness of his recent medical problem, and forced to abstain from tobacco as an immediate consequence of this event. This individual is much more likely to be receptive to smoking-cessation counseling and interventions (eg, nicotine patch, medication) delivered in the first few days after his hospitalization than he might have been in the months preceding this teachable moment. Similarly, both the diagnosis of cancer and the transition to cancer survivor are potential teachable moments for consideration of behavioral and lifestyle interventions among these target populations. Oncology clinicians seldom consider encouraging such interventions at diagnosis because of the complexity of initial cancer treatments and the difficulties in asking patients to take on even more than getting through their treatments. However, it is clear that among cancer patients completing their treatments and moving into a stage that Mullan described as "extended survival,"13 cancer survivors are looking for important ways to prevent a recurrence of their cancer and enhance the quality and length of their lives. Thus, the review in this issue of JCO provides an excellent status report on where our knowledge base is today on promoting the long-term health of the cancer survivors under our care. This report should be helpful to clinicians and survivors who are seeking information on this topic. However, there is perhaps another teachable moment that we should be considering. With 10 million cancer survivors alive today, and perhaps as many as 1 million new individuals in the United States joining those ranks each year, those of us in clinical oncology disciplines—whether surgeon, radiotherapist, medical or pediatric oncologist, nurse or social worker—are the real target of this teachable moment. The growth in the absolute number of cancer survivors and their public visibility (politicians, entertainers, athletes) is forcing oncologists to play a central role in setting the cancer-survivorship agenda, whether through clinical practice (as reflected in the results of the ASCO prevention survey noted above), research, or health policy activities. As professionals we must begin to focus more attention on this new phase in the cancer-treatment trajectory to better serve our patients. Numerous entities—including the Institute of Medicine, the President's Cancer Panel, and the Centers for Disease Control and Prevention—have reported recently on the needs of childhood and adult cancer survivors. These organizations are looking to oncology professionals to develop a coordinated strategy for providing follow-up medical care to the growing number of cancer survivors who represent the success of our cancer treatments. Thus, oncologists are faced with a teachable moment, along with their patients who are transitioning from patient to survivor. We have an opportunity to define what care of the cancer survivor should include and what each survivor can expect after completing their initial curative-intent therapy. Whether such ongoing care will be the responsibility of the oncologist or the primary care physician is not the main issue; however, oncologists must provide guidance and leadership in this area, because they are the most knowledgeable member of the health care team in understanding the potential exposures associated with cancer treatments and the potential for late effects that they entail. To this end, the ASCO Health Services Committee is developing a series of guidelines related to survivorship care (such as fertility, surveillance for second malignancies, cardiac late effects, osteoporosis, and other reproductive health effects), and the ASCO Cancer Prevention Committee has identified cancer survivors as an important target for prevention activities, as articulated in ASCO's most recent strategic plan.14 As a cross-cutting effort, ASCO also established a Survivorship Task Force to look across the organization's many activities to ensure coordination and successful advancement of these new initiatives and enhance more fundamental activities associated with education and training. Finally, through articles such as the one included in this issue, JCO is preparing oncology clinicians to capitalize on this teachable moment. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES 1. Cancer survivorship—United States, 1971-2001. MMWR Morb Mortal Wkly Rep 53:526-529, 2004[Medline] 2. Ganz PA: Late effects of cancer and its treatment. Semin Oncol Nurs 17:241-248, 2001[CrossRef][Medline] 3. Aziz NM, Rowland JH: Trends and advances in cancer survivorship research: Challenge and opportunity. Semin Radiat Oncol 13:248-266, 2003[CrossRef][Medline]
4. Hudson MM, Mertens AC, Yasui Y, et al: Health status of adult long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. JAMA 290:1583-1592, 2003
5. Gotay CC, Muraoka MY: Quality of life in long-term survivors of adult-onset cancers. J Natl Cancer Inst 90:656-667, 1998 6. Schag CA, Ganz PA, Wing DS, et al: Quality of life in adult survivors of lung, colon and prostate cancer. Qual Life Res 3:127-141, 1994[CrossRef][Medline]
7. Bower JE, Ganz PA, Desmond KA, et al: Fatigue in breast cancer survivors: Occurrence, correlates, and impact on quality of life. J Clin Oncol 18:743-753, 2000
8. Ganz PA, Desmond KA, Leedham B, et al: Quality of life in long-term, disease-free survivors of breast cancer: A follow-up study. J Natl Cancer Inst 94:39-49, 2002 9. Ramsey SD, Berry K, Moinpour C, et al: Quality of life in long term survivors of colorectal cancer. Am J Gastroenterol 97:1228-1234, 2002[CrossRef][Medline]
10. Jemal A, Murray T, Ward E, et al: Cancer Statistics, 2005. CA Cancer J Clin 55:10-30, 2005 11. Demark-Wahnefried W, Aziz NM, Rowland JH, et al: Riding the crest of the teachable moment: Promoting long-term health after the diagnosis of cancer. J Clin Oncol 23:5813-5830, 2005
12. McBride CM, Emmons KM, Lipkus IM: Understanding the potential of teachable moments: The case of smoking cessation. Health Educ Res 18:156-170, 2003 13. Mullan F: Seasons of survival: Reflections of a physician with cancer. N Engl J Med 313:270-273, 1985[Medline]
14. Lippman SM, Levin B, Brenner DE, et al: Cancer prevention and the American Society of Clinical Oncology. J Clin Oncol 22:3848-3851, 2004 Related Article
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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