Cancer survivors, now numbering about 14 million in the United States alone, are the focus of an upcoming Cancer Survivorship Symposium that will be held in January 2016 in San Francisco, California in collaboration with professional organizations representing primary care and family physicians. This meeting will provide an excellent venue for thinking about how best to expand existing models of care based on the needs of cancer patients and survivors, as well as their families and primary care physicians.
One of the key experiences described by cancer patients is the closeness of some relationships they develop with clinicians along the ‘journey’ or continuum of care. Oncologists also treasure the opportunity to bond with patients and to provide guidance during stressful and vulnerable times. Relationships crafted under these extreme conditions feel very close, and so it is hard for both the patient and clinician to know when it is time to let go. Transitions are often challenging and may be experienced as times of heightened anxiety. In my practice some patients express feeling surprised, or unprepared, when I recommend they return to their primary care physician, several years after they finish active treatment, preferring instead to maintain a close connection to the ‘cancer team’. Others are comfortable, and even relieved to transition back to a primary care or family clinician for all medical services, knowing they still have instant access to the oncology team if a problem or complication arises in the future. The key to a successful transition or ‘handoff’ is to ensure that every person treated for cancer is well informed; feels safe, connected, and ready to move on; and can recapture a sense of normalcy and wellbeing.
There are several situations to consider when thinking about medical care after cancer. Adults who were treated for cancer during childhood need to understand how their diagnosis and treatment may affect their future health, be prepared for additional testing if indicated, and have access to pertinent health information. For example, prior treatment may affect their risk of cardiac disease or their ability to have biological children, as well as other important determinants of health and wellbeing. Older adults may worry more about the impact of cancer treatment on their daily function and independence. For them, follow-up cancer care may require a multidisciplinary approach that takes into consideration their social needs as well as their physical needs. What matters most, is that patients receive assistance and guidance from experts at every step of the way, from diagnosis to end of active treatment or for the duration of a long and unremitting illness.
Care of cancer survivors is undergoing its own transition, reflecting the knowledge gained in recent years and the growing appreciation of the lasting impact of the diagnosis and treatment on body and soul. Some individuals need time to process their experiences and heal, others can snap back into healthy routines with less effort, and feel confident about moving on. Each person has his or her own unique way of coping. As a clinical oncologist, I take my cue from each patient and together we find the language that best describes her view of her own health and her experience as a patient treated for cancer. I do take advantage of these ‘teachable moments’ during follow-up visits to talk frankly about competing health risks, such as smoking, lack of exercise or obesity, and try to help each patient to invest in her own future health by making lifestyle changes that will yield future dividends.
My friend and colleague, Alan Astrow, wrote a moving reflection about his dual identity as oncologist and cancer survivor. (Astrow, JAMA 2012, vol 308, No 16). Astrow wrote that the term cancer survivor is meant as a form of self-empowerment but also reinforces the connection of a cancer patient to his or her physicians and cancer treatment center. Astrow suggests we focus instead on restoring a sense of wellness and hope for a future transformed through gratitude for the gift of life and a renewed sense of purpose and pleasure.