Cancer survivorship research: State of knowledge, challenges and opportunities

Figures & data

Table I.  Possible late effects of radiotherapy & chemotherapy.

Organ System	Late Effect/Sequelae of Radiotherapy	Late Effect/Sequelae of Chemotherapy	Chemotherapeutic drugs responsible
Bone and Soft Tissues	Short stature; atrophy, fibrosis, osteonecrosis	Avascular necrosis	Steroids
Cardiovascular	Pericardial effusion; pericarditis; CAD	Cardiomyopathy; CCF	Anthracylines Cyclophosphamide
Pulmonary	Pulmonary Fibrosis; Dec. Lung Volumes	Pulmonary fibrosis Interstitial pneumonitis	Bleomycin, BCNU Methotrexate, Anthracyclines
CNS	Neuropsychological Deficits, Structural Changes, Haemorrhage	Neuropsychological Deficits, Structural changes; Hemiplegia; seizure	Methotrexate
Peripheral Nervous System	–	Peripheral neuropathy; hearing loss	Platinum analogues, Vinca alkaloids
Hematological	Cytopenia, myelodysplasia	Myelodyplastic syndromes	Alkylating agents
Renal	Dec. creatinine clearance; Hypertension	Dec creatinine clearance; Inc. creatinine; Renal F Delayed Renal F	Platininum analogues Methotrexate Nitrosoureas
Genitourinary	Bladder fibrosis, contractures	Bladder fibrosis; Hemorrhagic cystitis	Cyclophosphamide
Gastrointestinal	Malabsorption; stricture; Abnormal LFT	Abnormal LFT; Hepatic fibrosis; cirrhosis	Methotrexate, BCNU
Pituitary	Growth hormone deficiency; pituitary deficiency	–	–
Thyroid	Hypothyroidism; nodules	–	–
Gonadal	Men: risk of sterility, Leydig cell dysfunction. Women: ovarian failure, early menopause	Men: sterility Women: sterility, prem menopause	Alkylating agents Procarbazine
Dental/oral health	Poor enamel & root formation; dry mouth	Tooth decay	multiple
Opthalmological	Cataracts; retinopathy	Cataracts	Steroids

Table II.  Follow-up care and surveillance for late effects.

Follow-up Visit	Content of Clinic Visit	Suggested Evaluative Procedures and ancillary actions
Chemotherapy/Radiotherapy Treatment Completion	1. Review Complete Treatment History	Develop late Effect Risk profile
	2. Calculate cumulative dosages of drugs	Summarize all information in previous column
	3. Document Regimen(s) administered and Radiation ports, dosage, machine	Provide copy to patient (or parent if minor child)
	4. Document patient age at diagn/Trt	Instruct that this summary should be provided to primary care or other health care providers
	5. Assess side effects during treatment
	6. Identify likely late effects
	7. Perform Baseline “grading” of late effects (CTCAEv.3.0, Garre, SPOG, others)	Keep copy of summary in patient chart
General Measures at every visit	1. Detailed history	Evaluate symptomatology, patient reports of issues
	2. Complete Physical exam	Review any intercurrent illnesses
	3. Review systems	Evaluate for disease recurrence, second neoplasms
	4. Meds, maint., prophylactic antibiotics	Systematic Evaluation of long term(persistent) and late effects (See Specific Measures)
	5. Education: GPA, school performance
	6. Employment history	Grade long term & late effects: Garre or SPOG criteria and note changes
	7. Menstrual status/cycle
	8. Libido, sexual activity	CBC; Urinalysis; Other tests depending upon exposure History and late effect risk profile
	9. Pregnancy & outcome
Specific Measures to evaluate late effects	Growth: Includes issues such as short stature, scoliosis, hypoplasia	Monitor growth (growth curve); sitting height, parental heights, nutritional status/diet, evaluate scoliosis, bone age, growth hormone assays, thyroid function, endocrinologist consult;
Relevance differs by:		orthopaedic consult (if appropriate)
1. Age at diagnosis/Treatment	Cardiac	EKG, Echo, afterload reduction, cardiologist consult
2. Specific drugs, regimens		Counsel against isometric exercises if high risk, advise OB/Gyn risk of cardiac failure in pregnancy
3. Combinations of Treatment modalities	Neurocognitive	History and Exam
4. Dosages administered		Communicate: School, Family, Special education
5. Expected Toxicities (based on mech of action of cytotoxic drugs (cell cycle dependent; proliferation kinetics).		Compensatory Remediation Techniques
		Neuropsych consult; CT or MRI; CSF; basic myelin protein
		Written instructions, appointment cards
6. Exceptions occur to the theoretical assumption that least susceptible organs/tissues are those that replicate slowly or not at all (Platinum analogues, methotrexate, anthracyclines).	Neuropathy	History/Exam: Neurolog exam, sensory ch hands/ feet, paresthesias, bladder, gait, vision, muscle strength
		Neurologist consult
	Gonadal toxicity	History for primary vs. secondary dysfunction, gonadal function (menstrual cycle, pubertal development/delay, libido); hormone therapy; interventions (bromocriptine)
7. Combinations of radiation/chemotherapy more often associated with late effects.		Premature menopause: hormone replacement unless contraindicated; DXA scans for osteoporosis; calcium Endocrinologist consult
		Reproductive Technologies
	Pulmonary	Chest X-ray; Pulmonary function tests; Pulmonologist consultation
	Urinary	Urinalysis; BUN/Creatinine; Urologist if hematuria
	Thyroid	Annual TSH; thyroid hormone repl; Endocrinologist
	Weight History	Evaluate Dietary intake (Food diary)/Physical Activity
		Nutritionist and/or Endocrinologist consult
	Lymphedema	History/ Exam: swelling, Sensations of heaviness/fullness
	Fatigue	Rule out hypothyroidism; anemia, cardiac/pulm sequelae,
		Evaluate sleep habits;
		Evaluate physical fitness and activity levels
		Regular physical activity unless contra-indicated
	Surgical Toxicity	Antibiotic prophylaxis (splenectomy)
	Gastrointestinal/Hepatic	Liver function, hepatitis screen, Gastro-enterologist consult
Screening for Second Malignant Neoplasms	Screening guidelines differ by age	Follow guidelines for age appropriate cancer screening (mammogram, pap smear, FOBT/ Flex Sig)
	Oncologist Consult	Mammog at age 30 if hx of mantle radiation for hodgkins
		Screen for associated cancers in HNPCC family syndrome
		Screen for ovarian cancer if hx of Breast ca and BRCAI II
Assess/Manage Co-morbidities	Osteoporosis; Heart Disease; Arthritis, etc.	History/Exam; Be Cognizant of risk; Appropriate Consult