What care and management are recommended for a cancer survivor?

Cancer Survivor Care and Management

Primary care clinicians should coordinate comprehensive survivorship care through a structured approach involving surveillance for recurrence, screening for second cancers, management of treatment-related effects, health promotion, and maintaining direct communication with the oncology team using a treatment summary and survivorship care plan. 1

Core Framework: Five Key Areas of Survivorship Care

The American Cancer Society and ASCO guidelines establish five essential domains for managing cancer survivors 1:

1. Surveillance for Cancer Recurrence

• Follow-up can be provided by either oncologists or primary care physicians with equivalent outcomes 1
• Most survivors will eventually transition back to primary care, though they remain at indefinite risk for treatment complications and cancer recurrence 1
• Shared care between oncology and primary care is an effective model 1

2. Screening for Second Primary Cancers

• Continue routine cancer screening per standard guidelines 1
• Survivors face elevated risk for developing new primary malignancies 2

3. Assessment and Management of Long-Term and Late Effects

Physical Effects to Monitor: 1

• Cardiovascular complications from chemotherapy and radiation 1
• Musculoskeletal issues including bone health 1
• Neuropathy (assess with validated tools like Total Neuropathy Score; treat with duloxetine for moderate cases) 1
• Fatigue (assess with MDASI, BFI, or FACT instruments) 1
• Bowel/gastrointestinal dysfunction particularly after colorectal cancer treatment 1
• Dental and oral health (monitor for dry mouth, taste changes) 1

Psychosocial Effects to Screen For: 1

• Depression and anxiety (screen at least annually using tools like the Distress Thermometer) 1
• Cognitive dysfunction (screen for contributing factors like depression; refer for neurocognitive training if positive) 1
• Fear of recurrence 1
• Body image and sexual dysfunction 1
• Higher distress risk in survivors with ostomies or sexual dysfunction 1

Management Approach: 1

• Use in-office counseling, pharmacotherapy, or exercise prescription as appropriate
• Refer to specialists when office-based interventions are insufficient
• For chronic fatigue, refer to rehabilitation services

4. Health Promotion

Physical Activity: 1

• Recommend 150 minutes of physical activity per week plus strength training 1
• Exercise interventions improve outcomes and should be systematically promoted by both oncology and primary care 1

Nutrition: 1

• Follow ACS Nutrition and Physical Activity Guidelines for Cancer Survivors 1
• Refer survivors with chronic bowel problems or malabsorption to registered dietitians 1
• Ensure adequate vitamin D status and calcium intake 1

Smoking Cessation: 1

• Smokers with cancer history have nearly twice the mortality risk compared to non-smokers 1
• Counsel all survivors to avoid tobacco and offer cessation support 1

5. Care Coordination and Practice Implications

Survivorship Care Plan (SCP): 1

• Primary care clinicians must obtain a treatment summary and survivorship care plan from the oncology team 1
• The treatment summary should include: cancer type and stage, surgery details, chemotherapy agents with cumulative doses, radiation therapy fields and doses 1
• The SCP should specify: timing of follow-up imaging and tests, risk for late effects, surveillance recommendations 1
• PCPs who receive SCPs report increased confidence, better preparation for survivor care, and changes in patient management 3

Communication Strategy: 1

• Maintain direct communication with the oncology team throughout diagnosis, treatment, and post-treatment phases 1
• Clearly delineate roles: oncology manages cancer-specific treatment decisions; primary care coordinates general medical care, preventive services, and comorbidity management 1
• Leave complex, rapidly-changing cancer treatment decisions to the oncology team 1

Family and Caregiver Inclusion: 1

• Include caregivers, spouses, or partners in survivorship care appointments 1
• Caregivers provide consistent care for 14-24 months post-diagnosis and have their own unmet physical and psychosocial needs 1
• Most caregivers are older adults managing their own health conditions 1

Practical Implementation

Primary Care Physician Role: 1

• Serve as general medical care coordinator throughout the cancer continuum 1
• Focus on evidence-based preventive care and management of pre-existing comorbidities 1
• Regularly assess overall physical and psychosocial status 1
• Make appropriate referrals for psychosocial, rehabilitative, or specialist care 1

Transition Timing: 1

• Some survivors return to primary care immediately after treatment completion 1
• Others transition only after being considered low risk for recurrence or late effects 1
• Approximately 75% of breast, colorectal, and prostate cancer survivors see primary care providers, with these percentages remaining stable over time 4

Common Pitfalls to Avoid

Survivor Preferences vs. Optimal Care: 5

• Most survivors (52%) prefer follow-up with cancer specialists due to perceived lack of primary care cancer expertise 5
• Only 38% initially see a role for primary care in cancer follow-up 5
• Despite preferences, evidence shows primary care follow-up achieves equivalent outcomes for recurrence detection, quality of life, and patient satisfaction 1

Inadequate Health Behavior Counseling: 1

• Diet and physical activity counseling often depends on provider preference rather than systematic implementation 1
• Both oncology and primary care teams must consistently reinforce healthy behaviors 1
• Young and educated survivors with more comorbidities are more likely to receive this counseling, creating disparities 1

Insufficient Coordination: 1, 6

• Coordination between oncology and primary care remains challenging 1
• Lack of clear role delineation and communication gaps compromise care quality 1, 6
• Electronic health records with integrated prompts and shared access can facilitate coordination 1