Taking Care of Second Cancer Risk

Krista L. Wilkins, PhD, RN; Roberta L. Woodgate, PhD


Cancer Nurs. 2012;35(1):55-62. 

In This Article

Abstract and Introduction


Background: Cancer survivors are living longer and are at greater risk of developing cancer than the general population. Promotion of healthy lifestyle behaviors and provision of regular follow-up care may modify the evolution of a second cancer diagnosis. Little is known, however, about cancer survivors' decision making and actions related to modifying second cancer risk.
Objective: Part of a larger mixed-method study of second cancer risk, qualitative interview data were collected to arrive at an interpretive description of how cancer survivors modify their second cancer risk, and how nurses and other healthcare professionals can best support survivors throughout the cancer survival trajectory.
Interventions/Methods: Semistructured interviews were conducted with 22 cancer survivors (16 women and 6 men) drawn from a provincial cancer registry. The cancer survivors ranged in age from 19 to 87 years. The cancer history of the participants varied. Data were analyzed using the constant comparative method.
Results: Two themes that emerged from the interviews that speak to how cancer survivors modified their second cancer risk were (1) how I take care of my second cancer risk and (2) support I need to take care of my second cancer risk.
Conclusions: For many cancer survivors, awareness of the benefits of taking care of second cancer risk does not translate into action.
Implications for Practice: Study findings reinforce that more needs to be done in supporting cancer survivors in taking care of second cancer risk.


Advances in early detection and treatment of cancer have transformed the disease from a death sentence to a disease that is now curable in many individuals. Estimates of enhanced survival suggest that 75% to 82% of Canadian adults and children with a diagnosis of cancer can expect to be alive in 5 years.[1] As the number of individuals surviving cancer grow, health problems that may occur when individuals are considered "cured" of their cancer, the season of permanent survival,[2] are fast emerging as a public health concern because being cancer-free does not mean being free from the effects of cancer or its treatment.

A most concerning long-term health issue for cancer survivors is a second cancer diagnosis because second cancers predispose cancer survivors to morbidity and early mortality.[3–5] Studies consistently show that cancer survivors are at greater risk of developing cancer compared with the general population, particularly those with a diagnosis of cancer at a younger age, those who have been exposed to high-dose radiation therapy and certain chemotherapies, and those with a known genetic predisposition to cancer, although the latter risk is small.[3,4]

Promotion of healthy lifestyle behaviors and provision of longterm follow-up care that includes cancer screening may facilitate the identification and management of late effects including second cancers and reduce the frequency of severe complications and morbidity, easing the impact on the healthcare system.[6] Despite their second cancer risks, most cancer survivors are much like the population at large—inactive lifestyle; overweight or obese; suboptimal fruit, vegetable, and fiber intake; high consumption of tobacco and alcohol; and high intakes of saturated fat.[7–11] These lifestyle behaviors are particularly harmful for cancer survivors because they may magnify second cancer risks associated with cancer treatments. For example, survivors of Hodgkin disease who were treated with radiation and who smoke are at greater risk for lung cancer than nonsmokers with the same cancer history.[12]

Long-term follow-up care that includes cancer screening is warranted for cancer survivors because many risk factors for second cancers cannot be manipulated or present limited opportunities for change (eg, family history). Evidence-based screening formany second cancers, including timing of screening, frequency of screening, and corresponding attributes of the tests (eg, specificity, sensitivity) is lacking.[6] However, the scant evidence that does exist has resulted in the development of risk-based screening guidelines for second cancers based on the severity of risk.[4]

Despite the potential benefits of long-term follow-up, recent studies show that as many as 60% of cancer survivors report receiving no regular medical follow-up.[10,11] Furthermore, the prevalence of cancer screening in this population is typically below optimal levels recommended for the general population.[13–16] Cancer screening is very poor among young cancer survivors, those with a history of high-risk cancer treatment, and those at highest risk for colon, breast, or skin cancer.[14,16,17]

Personal beliefs and emotions are key determinants of the extent to which cancer survivors engage in cancer prevention activities that may modify the evolution of second cancer risks. Cancer prevention activities among cancer survivors are typically marked by "ambivalent engagement."[18] Cancer survivors generally report ambivalent feelings toward the effectiveness of engaging in cancer prevention activities, particularly weight management, because they reject lifestyle factors as influencing cancer development. Instead, they identify external factors, such as stress and environment, as the likely sources of cancer.[18]As Bober and colleagues[19] found in interviewing Hodgkin disease survivors, cancer survivors avoided cancer screening for 3 reasons: (1) they struggled to reconcile messages that they were "cured" with the idea of being at increased risk for second cancers; (2) they felt helpless in preventing a second cancer; and (3) they received confusing recommendations over the initiation and frequency of cancer screening.

Although this groundbreaking work provided a beginning understanding of the strategies that cancer survivors used to deal with second cancer risk, more qualitative research is needed to explicitly explore cancer survivors' decision making and actions related to modifying second cancer risk. The meanings cancer survivors assign to living with second cancer risk are described elsewhere.[20] This article presents specific findings detailing cancer survivors' perspectives on how they modify their second cancer risk and how nurses and other healthcare professionals can best support survivors throughout the cancer survival trajectory.