Correspondence
Cancer Survivorship: Is There a Role for Cancer Survivor Clinics? The population of survivors of cancer is increasing worldwide. In Italy, 2,243,953 patients (4% of the Italian population) survived after a cancer diagnosis in 2006.1 The drafting of survivorship care plans (SCPs), consisting of a written treatment summary and a follow-up care plan (addressing cancer recurrence, primary and secondary cancer prevention, and the management of common long-term and late cancer and/or treatment effects), is regarded by both the Institute of Medicine2 and the American Society of Clinical Oncology3 as an essential step in the care of survivors of cancer. This is certainly true within the context of a collaboration and information sharing between survivors, oncology providers, and primary care physicians, with the ultimate goal of fostering the long-term health of the survivors. However, Salz et al4 recently reported in Cancer that although oncology providers have positive feelings regarding SCPs, only 52% of them ever provided any component of an SCP to their patients. As suggested by the authors, the reasons for this behavior are attributable to: 1) the lack of time and staff; 2) the failure to identify the type of information to be included in the SCPs; 3) doubts concerning the relevance of SCPs to survivors of cancer; and 4) the lack of reliable data demonstrating an improved outcome resulting from SCPs. Ultimately, the lack of integration of SCPs into clinical practice is due to the absence of definite guidance regarding what constitutes standards of care for survivors of cancer. Moreover, it is intriguing to note that, within the context of pediatric cancers, for which the mature data arising from a long period of follow-up led to the development of guidelines for the screening and prevention of cancer and/or treatment side effects, the results of a recent report5 have emphasized the lack of comfort among general internists with available surveillance plans and the preference to follow patients in collaboration with cancer centers. We propose the establishment of cancer survivor clinics (CSCs),6,7 which consist of health professionals (ie, medical oncologists; radiation therapists; psychologists; nurses; and other physicians such as cardiologists, gynecologists, and urologists) dedicated to the care of survivors of cancer and willing to assume a leadership role in the 1908
drafting of SCPs. The number of these CSCs should be planned in relation to the estimated number of survivors of cancer in each country and designed within the medical oncology departments. CSCs should assess: 1) the occurrence of any known side effects from cancer or its treatment (ie, neurocognitive problems, premature menopause, infertility, cardiorespiratory system dysfunctions, and chronic fatigue); 2) the concomitant presence of comorbidities and their influence on the patient’s general health status; 3) psychological disturbances (ie, fear of cancer recurrence, anxiety, depression, and body image perception disorders); and 4) problems regarding social and employment reintegration. Moreover, CSCs should provide screening guidelines for cancer recurrence and second primary tumors, design proper clinical follow-up pathways, promote behavioral changes (ie, smoking cessation and alcohol intake reduction), and improve screening and prevention programs for the relatives of cancer survivors. In particular, CSCs should focus on the care of long-term survivors of cancer who we have previously defined as disease and treatment free for at least 5 years.7 We propose a 1-time consultation model of survivorship care in which survivors at the end of the treatment phase should be referred to CSCs that will define personalized follow-up care plans based on different risks of disease recurrence and late side effects of cancer and/or its treatments. Further consultations should be defined according to the individual needs of survivors. Communication between CSCs and primary care physicians should be encouraged and CSCs should assume a coordinating role between survivors, their relatives, and primary care physicians in the promotion of an increased awareness of the unique aspects of survivorship care. Moreover, we believe that CSCs play some unique roles that cannot be performed by primary care practitioners. Particular among these is psychological support for survivors of cancer and their families, with the aim of facilitating social rehabilitation, employment, and education through the promotion of meetings and seminars and the sharing of information regarding several aspects of survivors’ health. Finally, as part of a health policy aimed at reducing unnecessary expenditures, we believe that the establishment of CSCs will not represent additional costs because they are specifically designed to avoid the redundancy of interventions and to respond to specific needs. Studies of Cancer
June 15, 2014
Correspondence
cost-effectiveness should be encouraged to confirm this belief. FUNDING SUPPORT No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures.
5. Suh E, Daugherty CK, Wroblewski K, et al. General internists’ preferences and knowledge about the care of adult survivors of childhood cancer: a cross-sectional survey. Ann Intern Med. 2014; 160:11-17. 6. Tirelli U, Spina M, Augello AF, Berretta M, Annunziata MA, Bongiovanni M. Is it better to transfer long-term cancer survivors to general practitioners or develop clinics for long-term survivors within the cancer centers? J Clin Oncol. 2014;32:257. 7. Simonelli C, Annunziata MA, Chimienti E, Berretta M, Tirelli U. Cancer survivorship: a challenge for the European oncologists. Ann Oncol. 2008;19:1216-1217.
Ernesto Zanet, MD
REFERENCES 1. AIRTUM Working Group. Italian cancer figures, report 2010: cancer prevalence in Italy. Patients living with cancer, long-term survivors and cured patients [in English, Italian]. Epidemiol Prev. 2010;34(5-6 suppl 2):1-188. 2. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2005. 3. McCabe MS, Bhatia S, Oeffinger KC, et al. American Society of Clinical Oncology statement: achieving high-quality cancer survivorship care. J Clin Oncol. 2013;31:631-640. 4. Salz T, McCabe MS, Onstad EE, et al. Survivorship care plans: is there buy-in from community oncology providers [published online ahead of print December 10, 2013]? Cancer. doi: 10.1002/cncr.28472.
Cancer
June 15, 2014
Unit of Cell Therapy and High Dose Chemotherapy Centro di Riferimento Oncologico (CRO) Aviano National Cancer Institute Aviano, Italy
Mariagrazia Michieli, MD Unit of Cell Therapy and High Dose Chemotherapy Centro di Riferimento Oncologico (CRO) Aviano National Cancer Institute Aviano, Italy
Umberto Tirelli, MD Division of Medical Oncology A Centro di Riferimento Oncologico (CRO) Aviano National Cancer Institute Aviano, Italy DOI: 10.1002/cncr.28658, Published online March 11, 2014 in Wiley Online Library (wileyonlinelibrary.com)
1909
Cancer Survivorship: Is There a Role for Cancer Survivor Clinics? The population of survivors of cancer is increasing worldwide. In Italy, 2,243,953 patients (4% of the Italian population) survived after a cancer diagnosis in 2006.1 The drafting of survivorship care plans (SCPs), consisting of a written treatment summary and a follow-up care plan (addressing cancer recurrence, primary and secondary cancer prevention, and the management of common long-term and late cancer and/or treatment effects), is regarded by both the Institute of Medicine2 and the American Society of Clinical Oncology3 as an essential step in the care of survivors of cancer. This is certainly true within the context of a collaboration and information sharing between survivors, oncology providers, and primary care physicians, with the ultimate goal of fostering the long-term health of the survivors. However, Salz et al4 recently reported in Cancer that although oncology providers have positive feelings regarding SCPs, only 52% of them ever provided any component of an SCP to their patients. As suggested by the authors, the reasons for this behavior are attributable to: 1) the lack of time and staff; 2) the failure to identify the type of information to be included in the SCPs; 3) doubts concerning the relevance of SCPs to survivors of cancer; and 4) the lack of reliable data demonstrating an improved outcome resulting from SCPs. Ultimately, the lack of integration of SCPs into clinical practice is due to the absence of definite guidance regarding what constitutes standards of care for survivors of cancer. Moreover, it is intriguing to note that, within the context of pediatric cancers, for which the mature data arising from a long period of follow-up led to the development of guidelines for the screening and prevention of cancer and/or treatment side effects, the results of a recent report5 have emphasized the lack of comfort among general internists with available surveillance plans and the preference to follow patients in collaboration with cancer centers. We propose the establishment of cancer survivor clinics (CSCs),6,7 which consist of health professionals (ie, medical oncologists; radiation therapists; psychologists; nurses; and other physicians such as cardiologists, gynecologists, and urologists) dedicated to the care of survivors of cancer and willing to assume a leadership role in the 1908
drafting of SCPs. The number of these CSCs should be planned in relation to the estimated number of survivors of cancer in each country and designed within the medical oncology departments. CSCs should assess: 1) the occurrence of any known side effects from cancer or its treatment (ie, neurocognitive problems, premature menopause, infertility, cardiorespiratory system dysfunctions, and chronic fatigue); 2) the concomitant presence of comorbidities and their influence on the patient’s general health status; 3) psychological disturbances (ie, fear of cancer recurrence, anxiety, depression, and body image perception disorders); and 4) problems regarding social and employment reintegration. Moreover, CSCs should provide screening guidelines for cancer recurrence and second primary tumors, design proper clinical follow-up pathways, promote behavioral changes (ie, smoking cessation and alcohol intake reduction), and improve screening and prevention programs for the relatives of cancer survivors. In particular, CSCs should focus on the care of long-term survivors of cancer who we have previously defined as disease and treatment free for at least 5 years.7 We propose a 1-time consultation model of survivorship care in which survivors at the end of the treatment phase should be referred to CSCs that will define personalized follow-up care plans based on different risks of disease recurrence and late side effects of cancer and/or its treatments. Further consultations should be defined according to the individual needs of survivors. Communication between CSCs and primary care physicians should be encouraged and CSCs should assume a coordinating role between survivors, their relatives, and primary care physicians in the promotion of an increased awareness of the unique aspects of survivorship care. Moreover, we believe that CSCs play some unique roles that cannot be performed by primary care practitioners. Particular among these is psychological support for survivors of cancer and their families, with the aim of facilitating social rehabilitation, employment, and education through the promotion of meetings and seminars and the sharing of information regarding several aspects of survivors’ health. Finally, as part of a health policy aimed at reducing unnecessary expenditures, we believe that the establishment of CSCs will not represent additional costs because they are specifically designed to avoid the redundancy of interventions and to respond to specific needs. Studies of Cancer
June 15, 2014
Correspondence
cost-effectiveness should be encouraged to confirm this belief. FUNDING SUPPORT No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures.
5. Suh E, Daugherty CK, Wroblewski K, et al. General internists’ preferences and knowledge about the care of adult survivors of childhood cancer: a cross-sectional survey. Ann Intern Med. 2014; 160:11-17. 6. Tirelli U, Spina M, Augello AF, Berretta M, Annunziata MA, Bongiovanni M. Is it better to transfer long-term cancer survivors to general practitioners or develop clinics for long-term survivors within the cancer centers? J Clin Oncol. 2014;32:257. 7. Simonelli C, Annunziata MA, Chimienti E, Berretta M, Tirelli U. Cancer survivorship: a challenge for the European oncologists. Ann Oncol. 2008;19:1216-1217.
Ernesto Zanet, MD
REFERENCES 1. AIRTUM Working Group. Italian cancer figures, report 2010: cancer prevalence in Italy. Patients living with cancer, long-term survivors and cured patients [in English, Italian]. Epidemiol Prev. 2010;34(5-6 suppl 2):1-188. 2. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2005. 3. McCabe MS, Bhatia S, Oeffinger KC, et al. American Society of Clinical Oncology statement: achieving high-quality cancer survivorship care. J Clin Oncol. 2013;31:631-640. 4. Salz T, McCabe MS, Onstad EE, et al. Survivorship care plans: is there buy-in from community oncology providers [published online ahead of print December 10, 2013]? Cancer. doi: 10.1002/cncr.28472.
Cancer
June 15, 2014
Unit of Cell Therapy and High Dose Chemotherapy Centro di Riferimento Oncologico (CRO) Aviano National Cancer Institute Aviano, Italy
Mariagrazia Michieli, MD Unit of Cell Therapy and High Dose Chemotherapy Centro di Riferimento Oncologico (CRO) Aviano National Cancer Institute Aviano, Italy
Umberto Tirelli, MD Division of Medical Oncology A Centro di Riferimento Oncologico (CRO) Aviano National Cancer Institute Aviano, Italy DOI: 10.1002/cncr.28658, Published online March 11, 2014 in Wiley Online Library (wileyonlinelibrary.com)
1909
