For Cancer Survivorship Programs, the Evidence Is In

As improved interventions in oncology have led to better outcomes, cancer survivorship has become an increasingly relevant area of clinical research and treatment.

To help steer this growing field, the American Society of Clinical Oncology (ASCO) recently released a new set of clinical practice guidelines focused on survivorship. The guidelines focus on common symptoms that affect the 13 million Americans surviving from cancer.

Areas of high need

The new guidelines concern three primary areas:

• Prevention and management of chemotherapy-induced peripheral neuropathy;
• Screening, assessment and management of fatigue; and
• Screening, assessment and care of anxiety and depressive symptoms.

“One of the goals of the guidelines was to address recommendations made in a 2006 Institute of Medicine Report, which outlined needed improvements to the care of cancer survivors,” explains Halle Moore, MD, staff oncologist at Cleveland Clinic and chair of the Taussig Cancer Institute Survivorship Committee. “These include developing evidenced-based practice guidelines as well as screening and assessment tools for managing late effects of cancer and cancer treatment.”

With this aim in mind, the guidelines focus on underrepresented areas of high clinical need. For example, neuropathy is a common sequelae of certain chemotherapy drugs. It can persist long after treatment abates. Although the guidelines advise that no single therapeutic can prevent symptoms, they recommend that clinicians consider offering duloxetine, gabapentin or tricyclic antidepressants as treatment.

As for fatigue, it is an expected part of active cancer treatment—and it may last for years after treatment. The guidelines encourage clinicians to screen for fatigue and associated symptoms, including sleep problems or nutritional deficits, in all cancer patients. If screening reveals a concern, doctors should discuss interventions (e.g., relaxation techniques) as well as pharmacotherapies with patients.

Finally, depression and anxiety can be debilitating from a physical, cognitive, social and emotional standpoint. As with fatigue, the guidelines recommend regular assessment of anxiety and depression symptoms. In some cases, patients will need referral for formal psychiatric treatment. Clinicians should frequently evaluate whether patients are adhering to any mental health treatment plan, too, according to the guidelines.

Putting policy into practice

The ASCO guidelines aim to improve patient outcomes while potentially reducing cost and variability of care. They cover a wide range of research to identify best practices.

The guidelines also provide concise summaries of each recommendation, which Dr. Moore says can help guide practice. Using these summaries, practitioners can assess their own practices and identify areas where they can improve. Even in places with strong survivorship programs in place, such as Cleveland Clinic, small changes, like adopting routine screening, may make a notable difference in patient care.

But putting the recommendations into action will come with varying degrees of success, she says. Practices that already routinely incorporate survivorship care planning will have an easier time meeting the guidelines because formal survivorship visits tend to include a number of the components recommended by ASCO.

“Oncologists and other cancer care providers deal with patients experiencing depression and fatigue on a daily basis,” she adds. “Many, however, do not systematically screen patients for these issues, as recommended in the guidelines. In addition, management often includes psychosocial and educational interventions, but the extent to which such resources are available may vary in different practice settings.”

Cultivating better science

In addition to identifying best practices, the guidelines note areas where information is lacking. Including these gaps should help drive future research.

“Data are limited on which treatment options for cancer-related fatigue are best,” Dr. Moore notes as an example. She adds that, at present, there is no standard effective means of preventing chemotherapy-associated peripheral neuropathy. Both are areas where future research can fill in information gaps.

As oncology populations live longer, the focus on the chronic and late effects of cancer and its treatment will continue. ASCO plans to release additional survivorship-focused guidelines over time to help ensure patients with cancer receive the care they need to live longer—and better—lives.