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.
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 Medicine and the American Society of Clinical Oncology 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 al 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 report 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 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.
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 cost-effectiveness should be encouraged to confirm this belief.