Many cancer survivors have unmet physical and mental needs related to their disease and its treatment

Even decades after being cured, many cancer survivors face physical and mental challenges resulting from their disease and its treatment. That’s the conclusion of a new study published early online in CANCER, a peer-reviewed journal of the American Cancer Society. The findings could help clinicians and other experts develop interventions that are tailored to the specific types of problems and concerns that cancer survivors may experience.

Increasingly, cancer patients are living many years after cancer treatment, with the number of US survivors expected to top 19 million by 2024. While many survivors do well after treatment, some experience continuing problems that can significantly impair their quality of life well beyond the magical 5-year survival milestone. These problems and challenges can vary by the type of cancer patients had and the treatments they received.

To assess the unmet needs of cancer survivors, Mary Ann Burg, PhD, LCSW, of the University of Central Florida in Orlando, and her colleagues looked at the responses from an American Cancer Society survey, wherein 1514 cancer survivors responded to the open-ended question, ‘Please tell us about any needs you have now as a cancer survivor that ARE NOT being met to your satisfaction.’ “This study was unique in that it gave a very large sample of cancer survivors a real voice to express their needs and concerns,” said Dr. Burg.

Survivors most frequently expressed physical problems, with 38 percent saying they were an issue. (Problems related to sexuality and incontinence among prostate cancer survivors were especially common.) Financial problems related to the costs of treatment also persisted long after treatment for 20 percent of respondents, with Black and Hispanic survivors being especially hard-hit. Anxiety about recurrence was a common theme expressed by survivors regardless of the type of cancer they had or how many years they had survived cancer. The number and type of unmet needs were not associated with time since cancer treatment.

Overall, we found that cancer survivors are often caught off guard by the lingering problems they experience after cancer treatment. In the wake of cancer, many survivors feel they have lost a sense of personal control, have reduced quality of life, and are frustrated that these problems are not sufficiently addressed within the medical care system,” said Dr. Burg. She noted that improvements are needed concerning public awareness of cancer survivors’ problems, honest professional communication about the side effects of cancer, and the coordination of medical care resources to help survivors and their families cope with their lingering challenges.

Burg et al. Current unmet needs of cancer survivors: Analysis of open-ended responses to the American Cancer Society Study of Cancer Survivors II. Cancer. 2015;EPub Ahead of Print [Abstract]

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Scientists map risk of premature menopause after cancer treatment

Women treated for the cancer Hodgkin lymphoma will be able to better understand their risks of future infertility after researchers estimated their risk of premature menopause with different treatments.

The findings, set out in the Journal of the National Cancer Institute, are based on the experience of more than 2,000 young women in England and Wales treated for the cancer over a period of more than 40 years.

Previous research has suggested that women with Hodgkin lymphoma who receive certain types of chemotherapy or radiotherapy are at increased risk of going through the menopause early – but there was insufficient information to provide patients with detailed advice.

But the new study, led by scientists at The Institute of Cancer Research, London, provides precise estimates of risk for women depending on which treatment types and doses they received and at what age – allowing doctors to give them detailed advice about their risks of future infertility.

The research was largely funded by Breakthrough Breast Cancer and involved researchers from across the UK at more than 50 universities and hospitals. The research team followed-up 2,127 women who had been treated for Hodgkin lymphoma in England and Wales between 1960 and 2004, and who had been aged under 36 at the time. All had received treatment with chest radiotherapy, sometimes alongside other treatments.

Some 605 of the women in the study underwent non-surgical menopause before the age of 40. This was a large enough number for the researchers to estimate accurate risks of menopause at different ages, depending on the mixture and doses of treatments they received and the age they received them.

The researchers produced a risk table which could help improve the advice that clinicians are able to give to women who have undergone treatment for the disease. Several of the treatments caused a sharp increase in premature menopause risk.

For example, a woman who had received six or more cycles of a standard chemotherapy regimen in her late 20s, but without receiving radiotherapy to the pelvic area, had a chance of around 18 per cent of undergoing menopause by the age of 30, or 58 per cent by age 40.

Overall, risk of premature menopause was more than 20-fold raised after ovarian radiotherapy, and also after some specific chemotherapy regimens. Risk of menopause by age 40 was 81 per cent after receiving ovarian radiotherapy at an overall dose of 5 or more Grays, and up to 75 per cent after chemotherapy, depending on the type, although only one per cent after receiving a chemotherapy regimen called ABVD.

Study leader Professor Anthony Swerdlow, Professor of Epidemiology at The Institute of Cancer Research, London, said, “Hodgkin lymphoma often affects younger women, and although fortunately most survive the disease, treatments including certain types of chemotherapy and pelvic radiotherapy can lead to premature menopause.”

We hope our study will help women to understand better, in consultation with their doctors, their risks of future infertility following treatment for this malignancy. By looking in a much larger group of women than previous studies of this type, we were able to produce age and treatment specific risk estimates that we hope will be of practical use to individual women. I’m extremely grateful to the patients and doctors who made it possible for us to produce this information.

Swerdlow et al., (2014). Risk of Premature Menopause After Treatment for Hodgkin’s Lymphoma. JNCI J. Natl. Cancer Inst., 106 (9): dju207, doi: 10.1093/jnci/dju207 [Abstract]

The Side Effects of Chemotherapy on the Body

Chemotherapy drugs are powerful enough to kill rapidly growing cancer cells, but they also can harm perfectly healthy cells, causing side effects throughout the body.

Cancer cells divide more quickly than healthy cells, and chemotherapy drugs effectively target those cells. Unfortunately, fast-growing cells that are healthy can be damaged too. There are many different chemotherapy drugs with the potential for many different side effects. These effects vary from person to person and from treatment to treatment.

Factors that play a role in side effects include other ongoing treatments, previous health issues, age, and lifestyle. Some patients experience few side effects while others feel quite ill. Although most side effects clear up shortly after treatment ends, some may continue well after chemotherapy has ended, and some may never go away.

Chemotherapy drugs are most likely to affect cells in the digestive tract, hair follicles, bone marrow, mouth, and reproductive system. However, cells in any part of the body may be damaged.

– See more at: http://www.healthline.com/health/cancer/effects-on-body#sthash.ZbSMeewY.dpuf

Updating cardiac screening guidelines for survivors of childhood cancer

Findings suggest that there is a long-term benefit in screening survivors at elevated risk for congestive heart failure. 

One of the first studies to analyze the effectiveness of screening survivors of childhood cancer for early signs of impending congestive heart failure (CHF) finds improved health outcomes but suggests that less frequent screening than currently recommended may yield similar clinical benefit. The researchers, in a study published in the Annals of Internal Medicine, utilized a simulation-based model to estimate the long-term benefits associated with routine screening.

The study’s findings suggest that the current CHF screening guidelines for survivors of pediatric cancer should be re-examined. The current guidelines recommend that survivors treated with chemotherapy agents known to affect long-term heart health be screened as often as every year, with a schedule dependent on their level of CHF risk. The new study suggests that screening survivors less often may be nearly as effective in detecting heart disease early. Some survivors might be better served by a different method of screening than the one currently used.

It is important to monitor survivors so we can reduce the late effects of treatment whenever possible, but we may be asking them to be tested too often, which burdens both individuals and the health care system,” says senior author Lisa Diller, MD, chief medical officer of Dana-Farber/Boston Children’s Cancer and Blood Disorders Center. “We think it is worthwhile to review the current CHF screening guidelines.

Our findings suggest that there is a long-term benefit in screening survivors at elevated risk for CHF,” says lead author Jennifer Yeh, PhD, of the Center for Health Decision Science at Harvard School of Public Health. “Yet less frequent screening than currently recommended may be reasonable when other factors are considered. We hope these results can help inform the ongoing discussion about screening childhood cancer survivors.”

As cure rates of pediatric cancers have risen, increasing numbers of survivors are at a substantially higher risk of heart disease, including congestive heart failure, compared to the general population. The increase in risk varies depending on several factors, including whether a patient was treated with anthracyclines, a class of drugs known to cause heart disease, and/or radiation to the heart. For instance, those who received no or low (<250 mg/m2) cumulative doses of anthracyclines have a relatively low lifetime risk of developing CHF, while those who received large (≥250 mg/m2) cumulative doses are at higher risk.

The Children’s Oncology Group (COG) currently recommends that survivors undergo screening by echocardiography for asymptomatic left ventricular dysfunction (ALVD). If left untreated, this clinically silent condition can progress to CHF, so clinicians typically prescribe beta blockers and ACE inhibitors to patients with signs of ALVD. COG recommends that patients at high risk of developing CHF be screened every year or two and those at low risk be screened every two or five years.

Survivors are screened for decades and face risks for other late effects, as well,” Diller says. “We need to consider carefully how often we ask survivors to be screened over the course of their lives, given the substantial cumulative economic impact and anxiety that screening may cause.”

To estimate the clinical benefits and cost-effectiveness of the current heart screening guidelines, Diller, Yeh and their co-author, cardiologist Anju Nohria, MD, of Brigham and Women’s Hospital, constructed a computer model of a virtual cohort of 15-year-olds who had survived cancer at least five years. Using data from the Childhood Cancer Survivors Study and the Framingham Heart Study, the researchers modeled the cohort’s CHF risk and clinical progression over the course of survivors’ lifetimes. Their analysis suggests that routine screening may prevent as many as one in 12 cases of CHF.

The authors then used Medicare data to estimate the costs and value (expressed in cost per quality-adjusted life year [QALY]) of different screening schedules (i.e., every 1, 2, 5 or 10 years) and methods (echocardiography versus cardiac magnetic resonance imaging [cMRI]) for the different CHF risk groups (i.e., low, high).

At a cost-effectiveness threshold of $100,000/QALY, the model’s results indicate that echocardiographic screening might not be the best value for resources invested to reduce lifetime CHF risk among survivors at low risk of developing the disease. On the other hand, the data suggest that biennial echocardiography screening may be a high-value strategy for high-risk survivors.

The simulation’s data also suggested that cMRI may be preferable to echocardiography as a screening method, with cMRI’s greater cost per test balanced by its greater sensitivity. According to the model, cMRI-based screening of low-risk survivors every 10 years and high-risk survivors every five years was more cost effective than any echocardiography-based schedule.

Lastly, the data suggest that it may be most beneficial to treat high-risk survivors before signs of ALVD even appear. For instance, proactively treating all high-risk patients in the virtual cohort with ACE inhibitors and beta blockers reduced their lifetime CHF risk more than if they received an echocardiograph every two years, although additional clinical studies on the benefit of the treatments are needed to support this strategy in practice.

The researchers relied on simulation modeling using the best available clinical and epidemiologic data because of the immense logistical obstacles to conducting prospective randomized clinical studies of survivors’ long-term cardiovascular outcomes. The number of survivors that clinical studies would need to enroll and follow for years is challenging given how rare childhood cancers are. Yet guidance on the health benefits associated with current recommendations is needed.

Our findings suggest that current recommendations for cardiac assessment may reduce systolic CHF incidence, but less frequent screening than currently recommended may be preferred,” the study concludes. “Possible revision of current recommendations is warranted.”

Yeh et al., (1014). Routine echocardiography screening for asymptomatic left ventricular dysfunction in childhood cancer survivors: A model-based estimation of the clinical and economic effects. Ann. Intern. Med., 160(10):661-671. doi:10.7326/M13-2266 [Abstract]