A new paradigm of survivorship care is needed that attempts to balance the patient’s total well-being against the often toxic treatment of the disease, suggests Deborah Korenstein, MD, Director of Clinical Effectiveness, Memorial Hospital, Memorial Sloan Kettering Cancer Center, NY. At the 2016 Cancer Survivorship Symposium, Dr Korenstein outlined a more personal approach to care: assessing the individual patient’s priorities and goals to balance long-term benefits and harms.
“For many patients, it is not only important to live as long as possible, but to live as normal a life as possible, which means optimizing functional status while minimizing debt and inconvenience,” said Dr Korenstein.
“I do not mean to suggest that all these things are equivalent,” she added, “but it is important for clinicians to consider the spectrum of outcomes that matter to patients and at least take all of them into account.” It is also important for providers to keep in mind the vulnerability of their patients.
Potential Harm of Cancer Treatment
Vulnerability generally involves the 3 domains of social, psychological, and physical, making cancer survivors a classic vulnerable population, Dr Korenstein explained. These vulnerabilities have been confirmed by recent data showing that cancer survivors are at an increased risk for several complications related to their treatment.
“For a very long time, clinicians didn’t have adequate knowledge of this, and were probably not aware enough of the risks. As a result, there’s been a concerted emphasis on not missing anything,” said Dr Korenstein.
She said that in addition to the increased risk for physical harm from interventions, survivors may be vulnerable to psychological complications, which include high rates of anxiety regarding surveillance testing known as “scanxiety.”
A growing body of evidence also suggests that survivors are at risk for financial harms. A 2014 survey of more than 2000 cancer survivors found that 30% reported cancer-related financial problems, with 8.6% reporting “a lot” of financial difficulties (Fenn KM, et al. J Oncol Pract. 2014;10:332-338). Younger and nonwhite patients were at a higher risk than other patients, which is important to keep in mind.
The fear of missing diagnoses in survivors can drive clinicians to a “checkbox approach” that fails to individualize care, and treatment guidelines, although variable, tend to be biased toward more aggressive care, according to Dr Korenstein.
To balance the benefits and harms of surveillance tests in cancer survivors, providers should be mindful of the quality of evidence driving them toward different practices.
“Whenever we prescribe treatments,” said Dr Korenstein, “we think about the obvious potential toxicities, but we should also consider the harms to diagnostic and screening tests.”
These harms include the hassle of the test itself, anxiety over false-positive results and subsequent testing, delays because of abnormal results, the treatment of overdiagnosed disease, and the obvious financial impact.
Although many studies document a high risk for complications, few gauge the efficacy of many interventions.
“These limitations in clinician knowledge can be a challenge,” said Dr Korenstein. “We need to push for better evidence of the impact of our different interventions, not just evidence of the risk in these patients. Obviously that’s easier said than done, but I think it’s something to strive for.”
The most critical component of this new paradigm is personalizing long-term survivorship care.
“With my patients, I try to frame the approach to care in terms of their individual goals and speak honestly about their overall prognosis….It’s not an easy thing to do, but it can be quite fulfilling.”
Dr Korenstein and colleagues have also been working hard to optimize and streamline care by ensuring that required tests are scheduled on the same day, and by eliminating unnecessary specialty care visits.
“In day-to-day practice, we can individualize risk assessment of benefits and harms of interventions, and we can work to meet patient goals, and not just check boxes,” Dr Korenstein concluded. “If we do that right, we can help our patients to really live, not just survive.”