Wellness in the cancer survivor and the General Practitioner
By Dr Justus Apffelstaedt
Over the last couple of decades, early diagnosis and treatment have meant, that what previously was a subacute lethal disease, has for many patients become a curable disease and even for those, who are incurable, more of a chronic disease akin to hypertension and diabetes: A dissociation of a cancer diagnosis and mortality has taken place. For example, for the common cancers of the female breast, the colon and the prostate, the long-term survival rates have increased to 91%, 90% and 98% respectively. This means, that general practitioners are exposed to a rapidly expanding pool of long-term survivors of cancer and must familiarize themselves with the long-term sequelae resulting of cancer therapy in order to preserve quality and quantity of the survivor’s life. So, what can be done?
First, aggressive search at short interval for the presence of metastatic disease with imaging and lab work is discouraged universally by guidelines of relevant professional organisations. Not only is it expensive and futile, as most cancers will not recur after appropriate primary therapy, but also suggests to the patient that the risk of recurrence is higher that it actually is and thus keep the patient in continuous fear that “something” may be discovered. That “something” then more often than not will turn out after expensive and at times invasive further investigations to be a variation of normal, degenerative changes or a benign innocuous lesion not requiring any further treatment. It also draws the attention of the clinician and the patient from the real issue that should be the focus of survivorship: Quality of life. Tellingly, most cancer survivors nowadays do not die of their cancer, but of the principal causes of death lead by cardiovascular disease.
Three issues related to cancer therapy are common to all cancer survivors to varying degrees, irrespective of the primary cancer and have been the focus much of recent research and guideline writing: Bone, cardiovascular and sexual health. While a discussion of the mechanisms generating side effects of particular chemotherapeutic agents and biologicals is beyond the scope of this article, several general recommendations apply. In oncology, it is a good rule of thumb, that a course of chemotherapy will age ovaries by about 10 years; much less is emphasized, that also in men chemotherapy will lead to at least a transient, but in many cases permanent decrease in testosterone levels. Add to that the direct effects of hormonal therapies – ovarian suppression, selective estrogen receptor modulators and aromatase inhibitors in females for breast cancer and antiandrogens in males for prostate cancer. This leads beyond the direct cardiotoxic effects of certain oncologic drugs such as anthracyclins and trastuzumab which to some degree are reversible to a metabolic environment that has been recognized to accelerate cardiac deterioration, bone loss and sexual dysfunction. The deleterious effects for example of cardiac problems, bone loss induced pathologic fractures and poor libido on the quality of life of the cancer survivor are self-evident.
Where does the general practitioner’s responsibility lie? It cannot be expected of medical, surgical and radiation oncologists, whose skills are the selection, administration and performance of specialist oncological therapies, to attend to recurrence-free, healthy patients for decades. Therefore, the general practitioner must take an active role in the management of the quality of life of the cancer survivor. First and foremost, the general practitioner should emphasize, that the patient’s chance of suffering a recurrence of cancer is slim and encourage a healthy life-style: Regular physical exercise, cessation of smoking, achievement of a normal weight, moderation in the use of alcoholic beverages, smoking cessation and pursuit of a healthy diet each in itself have all been shown to decrease recurrence rates significantly. Beyond that, the general practitioner cannot be expected to be current with all guidelines specific for cancer therapy induced morbidity but should be alert to the premature deterioration of physiological functions, screen for signs and symptoms of these and initiate appropriate work-up and basic treatment. Since this deterioration cannot be reliably differentiated in diagnosis and management from normal age-related deterioration and often becomes relevant only years and even decades after cancer therapy is completed, it falls squarely into the remit of good general practice. Attention to lipid metabolism, bone density and blood pressure control are anyway part of such practice. Most cancer follow-up guidelines therefore recommend placing follow-up of cancer patients after primary therapy is completed in general practice with an emphasis on maintenance of quality of life.
