BioSurveillance and Longitudinal Lifelong Guidelines

Abstract

Given the increased risk of a wide range of late effects faced by cancer survivors, lifelong follow-up of these patients are essential. Existing guidelines are largely based on the known types of late effects, their temporal trend and modifying risk factors after specific treatments for various primary malignancies. Well-established follow-up guidelines exist for survivors of pediatric malignancies, most of which are based on prior treatment exposures. Less data are available on the optimal follow-up strategies for survivors of adult-onset cancer. Additional efforts are needed to prospectively evaluate the feasibility and efficacy of the follow-up recommendations including screening and prevention strategies. Need to initiate transition from multidisciplinary oncology to medical community care through individualized survivorship care plan (p 5, paragraph 1). Community health care providers are unfamiliar with health risks associated with cancer survivors and need to be supplemented by patient education and self advocacy (p 5, paragraph 2, 3). Currently, deficiencies include lack of standard definitions of toxicity, use of variable testing strategies, inconsistency as to evaluation time in relation to therapeutic exposures (p 6, paragraph 1). Early identification leads to early intervention for late onset therapy-related complications (p 6, paragraph 4). NCCN guidelines provide follow-up algorithms for cancer relapse rather than late effects of treatment (p 8, paragraph 1). Long-term surveillance guidelines beyond 5 years are available for 15 different cancers and again are designed for detecting cancer recurrence (p 9, paragraph 2). Second malignant neoplasms (SMN) have been most actively pursued in Hodgkin's lymphoma survivors (breast cancer and lung cancer) (p 10, paragraph 3, p 11, paragraph 1, p 12). SMN skin cancers are increased in Hodgkin's lymphoma and TBI/BMT survivors (p 13). SMN uterine cancer is increased in breast cancer survivors on estrogen therapy by 50 % in high-risk women (p 19). Cardiovascular disease complications are seen after radiation in breast cancer and Hodgkin's lymphoma survivors, with varied guidelines for annual blood pressure, serum glucose and lipid screening, and utility of baseline stress test/echocardiogram (p 16). Endocrine deficiencies after head and neck radiation leads to 30-40 % risk of hypothyroidism (p 18). Osteopenia can occur due to increased bone turnover in treatment-induced ovarian ablation and prostate cancer treated with gonadotrophin-releasing hormone agonists (p 18). Osteonecrosis and bone fracture can occur after radiation doses of 60 Gy and have been shown in survivors of cervix cancer (p 18). Psychosocial distress issues include fear, anxiety, suicidal ideation, depression, highlighting importance of implementing routine psychological screening and access to mental health professionals (p 20). Future Directions Recognize need for adult guidelines in follow-up of cancer survivors, especially those treated by radiation +/- chemotherapy and surgery (p 20). Need information on feasibility, level of compliance efficacy, cost-effectiveness for surveillance strategies (p 20). Optimal types of testing and interventions, their timing and frequency needs to be better defined and assessed in prospective cohorts of cancer survivors (p 20). Develop internet contact and resources that may provide optimal means to maintain contact for long-term follow-up of cancer survivors in our highly mobile society (p 20).