With the risk of more than one in three getting cancer during a lifetime, each of us is likely to experience cancer, or know someone who has survived cancer. Although some cancer survivors recover with a renewed sense of life and purpose, what has often been ignored is the toll taken by cancer and its treatmenta "on health, functioning, sense of security, and well-being. Long lasting effects of treatment may be apparent shortly after its completion or arise years later. The transition from active treatment to post-treatment care is critical to long-term health. From Cancer Patient to Cancer Survivor focuses on survivors of adult cancer during the phase of care that follows primary treatment. The book raises awareness of the medical, functional, and psychosocial consequences of cancer and its treatment. It defines quality health care for cancer survivors and identifies strategies to achieve it. The book also recommends improvements in the quality of life of cancer survivors through policies that ensure their access to psychosocial services, fair employment practices, and health insurance. This book will be of particular interest to cancer patients and their advocates, health care providers and their leadership, health insurers, employers, research sponsors, and the public and their elected representatives.

From cancer patient to cancer survivor : lost in transition

The Italian SF-36 Health Survey: Translation, Validation and Norming

The purpose of the American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer. A systematic review of the literature was conducted using PubMed through April 2015. A multidisciplinary expert workgroup with expertise in primary care, gynecology, surgical oncology, medical oncology, radiation oncology, and nursing was formed and tasked with drafting the Breast Cancer Survivorship Care Guideline. A total of 1,073 articles met inclusion criteria; and, after full text review, 237 were included as the evidence base. Patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer-related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence. Primary care clinicians should counsel patients about the importance of maintaining a healthy lifestyle, monitor for post-treatment symptoms that can adversely affect quality of life, and monitor for adherence to endocrine therapy. Recommendations provided in this guideline are based on current evidence in the literature and expert consensus opinion. Most of the evidence is not sufficient to warrant a strong evidence-based recommendation. Recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, assessment and management of physical and psychosocial long-term and late effects of breast cancer and its treatment, health promotion, and care coordination/practice implications are made.This guideline was developed through a collaboration between the American Cancer Society and the American Society of Clinical Oncology and has been published jointly by invitation and consent in both CA: A Cancer Journal for Clinicians and Journal of Clinical Oncology. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission by the American Cancer Society or the American Society of Clinical Oncology.

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American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

Objective: To review the evidence from clinical trials of follow up of patients after curative resection for colorectal cancer. Design: Systematic review and meta-analysis of randomised controlled trials of intensive compared with control follow up. Main outcome measures: All cause mortality at five years (primary outcome). Rates of recurrence of intraluminal, local, and metastatic disease and metachronous (second colorectal primary) cancers (secondary outcomes). Results: Five trials, which included 1342 patients, met the inclusion criteria. Intensive follow up was associated with a reduction in all cause mortality (combined risk ratio 0.81, 95% confidence interval 0.70 to 0.94, P=0.007). The effect was most pronounced in the four extramural detection trials that used computed tomography and frequent measurements of serum carcinoembryonic antigen (risk ratio 0.73, 0.60 to 0.89, P=0.002). Intensive follow up was associated with significantly earlier detection of all recurrences (difference in means 8.5 months, 7.6 to 9.4 months, P Conclusions: Intensive follow up after curative resection for colorectal cancer improves survival. Large trials are required to identify which components of intensive follow up are most beneficial. What is already known on this topic There is a lack of direct evidence that intensive follow up after initial curative treatment for colorectal cancer leads to increased survival Guidelines are inconclusive and clinical practice varies widely What this study adds The cumulative analysis of available data supports the view that intensive follow up after curative resection for colorectal cancer improves survival If computed tomography and frequent measurements of serum carcinoembryonic antigen are used during follow up mortality related to cancer is reduced by 9-13% This survival benefit is partly attributable to the earlier detection of all recurrences, particularly the increased detection of isolated recurrent disease

https://www.bmj.com/content/bmj/324/7341/813.full.pdf

Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470204511701413.pdf

Delivering affordable cancer care in high-income countries

Objective. —To assess prospectively the impact on survival and health-related quality of life of two follow-up protocols in patients with early breast cancer. Design. —Randomized controlled clinical trial. Setting. —Multicenter study involving 26 general hospitals in Italy. Patients. —A consecutive sample of 1320 women younger than 70 years with stage I, II, and III unilateral primary breast cancer. Intervention. —Patients were randomly assigned to an intensive surveillance, which included physician visits and performance of bone scan, liver echography, chest roentgenography, and laboratory tests at predefined intervals (n=655), or to a control regimen (n=665), in which patients were seen by their physicians at the same frequency but only clinically indicated tests were performed. Both groups received a yearly mammogram aimed at detecting contralateral breast cancer. Main Outcome Measures. —Primary end points were overall survival and health-related quality of life. Results. —Compliance to the two follow-up protocols was more than 80%. At a median follow-up of 71 months, no difference was apparent in overall survival with 132 deaths (20%) in the intensive group and 122 deaths (18%) in the control group. No significant differences were apparent in time to detection of recurrence between the two groups. Measurements of health-related quality of life (ie, overall health and quality-of-life perception, emotional well-being, body image, social functioning, symptoms, and satisfaction with care) at 6,12, 24, and 60 months of follow-up did not show differences by type of care received. Conclusions. —Results of this trial support the view that a protocol of frequent laboratory tests and roentgenography after primary treatment for breast cancer does not improve survival or influence health-related quality of life. Routine use of these tests should be discouraged. (JAMA. 1994;271:1587-1592)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=372979&pdfFileName=jama_271_20_031.pdf

Impact of Follow-up Testing on Survival and Health-Related Quality of Life in Breast Cancer Patients: A Multicenter Randomized Controlled Trial

A total of 1095 patients with operable breast cancer and en-rolled in a randomized clinical trial were analysed for estrogen (ER) and progesterone (PgR) receptor content of their primary tumor, and the relationships between steroid receptor status and several epidemiologic characteristics were studied. The proportion of ER+ and median ER levels increased with age: compared to women younger than 40, those aged 66 or more were approximately three times more likely to have an ER+ tumor (OR = 3.0, 95% C.I. = 1.6–5.7). This difference tended to be more marked after comparison between patients with ER > 100 fmol/mg protein and ER- within the same age groups: OR = 7.04, 95 % C.I. = 2.89–17.12. No association emerged between age and PgR. ER status and concentrations were independent of menopausal status after adjustment for age, whereas the proportion of PgR+ and PgR levels were significantly lower in postmenopausal patients of the same age. The distribution of ER and PgR profiles was similar in relation to family history of breast cancer, reproductive events and other selected epidemiologic characteristics of the patients.

M. Indelli

Papers

Impact of Follow-up Testing on Survival and Health-Related Quality of Life in Breast Cancer Patients: A Multicenter Randomized Controlled Trial

Breast cancer estrogen and progesterone receptors: Associations with patients' clinical and epidemiologic characteristics