NCCN Issues Guidelines for Survivorship Care

Whereas survivorship should be viewed as another stage in the cancer journey—the same as diagnosis and treatment—concerns related to surviving cancer have been largely neglected. This is beginning to change, as evidenced by new guidelines revealed by the National Comprehensive Cancer Network (NCCN) at the group’s 18th Annual Conference held in Hollywood, Florida.^1,2

Although the number of cancer survivors has increased exponentially over the past 30 years, survivorship care is still an overlooked phase of the cancer care continuum, according to Jennifer A. Ligibel, MD, of Harvard Medical School and the Dana-Farber Cancer Institute, Boston, Massachusetts, who serves on the NCCN Guidelines survivorship panel. Many survivors and their families remain “lost in transition,” she said.

To address the issues faced by survivors and their families and to offer practical recommendations for use in the clinic, these guidelines were developed. “They are intended as a library of tools for a provider to use when assessing a cancer survivor,” said Crystal S. Denlinger, MD, of Fox Chase Cancer Center, Philadelphia, Pennsylvania, who serves as chair of the NCCN Guidelines survivorship panel. The guidelines should help to standardize what is now a system of heterogeneous survivorship care across the country.

Survivorship Issues Have Been Ignored

Cancer survivors have a variety of needs. However, there are common components of care that all should receive, centering on prevention, surveillance, intervention, and coordination of care, Ligibel noted. In particular, survivorship care should address the potential for long-term side effects of treatment, the importance of follow-up visits, maintenance of a healthy lifestyle, prevention of new and recurrent cancer, and access to psychological services, according to the landmark 2005 Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition. Until recently, clear guidelines for caring for these patients, including skills training for oncology providers, have been lacking, she said.

The inaugural NCCN Guidelines on Survivorship, unveiled at the meeting, focus on the impact of a cancer diagnosis on the adult survivor, with subtopics related to anxiety and depression, cognitive function, exercise, immunizations/infections, fatigue, pain, sexual function, and sleep disorders. At the conference, Ligibel and Denlinger addressed exercise, cognitive function, immunization, and sexual function.

The survivorship guidelines are not intended to replace the existing disease-specific guideline recommendations for cancer surveillance, but to accompany them.

Exercise Is Always Beneficial

The benefit of exercise has been shown for patients with breast, colorectal, or prostate cancer. In breast cancer, Ballard-Barbash and colleagues concluded from a systematic literature review that women who exercise have lower breast cancer–specific and overall mortality than less active individuals (Ballard-Barbash R, et al. J Natl Cancer Inst. 2012;104:815-840). In the prospective Nurses’ Health Study, breast cancer recurrences were reduced by 50%, and mortality was lower as well, for women who exercised more than 3 hours/week, versus more sedentary women (Holmes MD, et al. JAMA. 2005;293:2479-2486). Similar associations have been shown for colon cancer (Meyerhardt JA, et al. J Clin Oncol. 2006;24:3535-3541) and prostate cancer. In a recent study of the latter, men with clinically localized prostate cancer who walked briskly for at least 3 hours/week had a 57% lower risk of disease progression than did men who walked more slowly for less time (Richman EL, et al. Cancer Res. 2011;71:3889-3895). The NCCN survivorship guidelines, therefore, strongly encourage physical activity, tailored to the individual’s abilities and preferences (with special considerations for specific populations, such as persons with ostomies or peripheral neuropathy). In general, the recommendation is for 75-150 minutes/week of moderate-intensity activity coupled with strength training and stretching.

Cognitive Dysfunction Is Increasingly Recognized

“We struggled with this topic a bit as a panel, because cognitive function has been so ill-defined,” Ligibel acknowledged. Cognitive dysfunction manifests as problems with memory, executive function, learning, and processing speed. Patients most at risk include those with primary central nervous system tumors or brain metastases, but cognitive dysfunction in breast cancer and lymphoma patients has been commonly reported.

The NCCN panel presented general principles related to this complication while acknowledging a lack of evidence-based guidance. Clinicians should screen for reversible contributing factors and should approach the evaluation with a focused history first. Imaging or neuropsychologic evaluation is suggested in the presence of focal neurologic deficits, known metastatic disease, or a primary brain tumor. Practical interventional strategies are centered on patient/family education and counseling.

Immunizations Are Important

Because of a higher than normal risk for infections and inadequate immunization, the guidelines recommend that adults with cancer routinely receive appropriate vaccinations based on their age and medical condition. Vaccines considered safe for cancer patients, transplant recipients, and close contacts include those for influenza, pneumonia, meningitis, and hepatitis. Live attenuated vaccines, such as those for measles, mumps, and rubella, are contraindicated or should be used with caution, Denlinger said. She recommended vaccinating patients at least 3 weeks prior to starting cancer treatment to obtain the full benefit of immunity.

Sexual Dysfunction Is Underappreciated

Sexual dysfunction has been reported by up to 90% of prostate cancer survivors, 75% of rectal cancer survivors, and 50% of breast and gynecologic cancer survivors, although this multifactorial problem is rarely discussed with healthcare providers. In addition to erectile dysfunction for men and dyspareunia and vaginal atrophy for women, other problems common to both genders are loss of libido, infertility, negative body image, and partner distress, said Denlinger. “Complex factors” are at play, she added.

The NCCN guidelines provide validated tools for assessment—a brief sexual symptom checklist for women and a sexual health inventory for men—along with suggestions for additional evaluation and treatment. “We tried hard to minimize the interventions to things an oncology provider could do versus things that need to be referred,” she said.

Moving the Guidelines Into the Clinic

Both Ligibel and Denlinger acknowledged that incorporating these guidelines into daily clinical practice may be initially challenging, but the baseline tools provided in the guidelines should help. They recommended evaluating survivors for survivorship issues at regular intervals using standardized questionnaires to assess symptoms, new-onset and late effects of treatment, receipt of preventive health services, and personal health behaviors. Such is meant to be “a quick, down, and dirty screening assessment” that will trigger a larger discussion of the patient’s big concerns, Denlinger said.

References
1. Denlinger CS, Ligibel JA. New NCCN guidelines for survivorship. Presented at: 18th Annual Conference of the National Comprehensive Cancer Network; March 13-17, 2013; Hollywood, FL.
2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Survivorship. Version 1.2013.