New Cancer Survivorship Guidelines Issued by NCCN

Roxanne Nelson

March 18, 2013

HOLLYWOOD, Florida — For the first time, the National Comprehensive Cancer Network (NCCN) has issued practice guidelines for survivorship.

"This guideline becomes a number of subguidelines to help clinicians provide better oncology care to cancer survivors," said Jennifer A. Ligibel, MD, an attending physician at the Dana-Farber/Brigham and Women's Cancer Center in Boston Massachusetts.

Dr. Jennifer Ligibel

Dr. Ligibel copresented highlights of these guidelines here at the NCCN 18th Annual Conference.

Although the definition of survival can vary considerably, the NCCN has endorsed the very broad National Cancer Institute definition, which considers survival any time after diagnosis, Dr. Ligibel explained.

The guidelines also "acknowledge the role of family members and caregivers, although they do not address them directly," she noted. They are meant to be a companion to disease guidelines, and do not address issues such as following an individual for recurrence or mammography schedules.

The survivorship guidelines focus on the post-treatment period. That is a neglected phase of the cancer care trajectory, because some clinicians lack the related education and training, and there can be a lack of coordination between cancer specialists and primary care providers, according to Dr. Ligibel.

Eight Topics Covered

The NCCN Guidelines for Survivorship cover 8 distinct areas: anxiety and depression, cognitive function, exercise, fatigue, immunizations and infections, pain, sexual function, and sleep disorders.

The areas of anxiety and depression, fatigue, pain, and sleep disorders are adapted from existing NCCN guidelines, but Dr. Ligibel pointed out that the NCCN has not previously addressed exercise, cognitive function, sexual function, or immunizations and infections.

Exercise is important because observational evidence has linked exercise after diagnosis to better outcomes. In addition, interventional studies have shown that increasing exercise after a cancer diagnosis leads to physical and physiologic benefits in cancer survivors.

A significant proportion of survivors are at risk for cognitive decline, she noted. Some studies have shown an association with chemotherapy, and up to 78% of patients report cognitive difficulties after treatment for breast cancer or lymphoma. In addition, recent studies have suggested that up to one third of patients report difficulties with memory and processing prior to receiving chemotherapy.

Dr. Crystal Denlinger

Vaccination is also an important area, because survivors are at elevated risk for infection because of cancer treatment, explained copresenter Crystal S. Denlinger, MD, an attending physician and assistant professor of medical oncology at the Fox Chase Cancer Center in Philadelphia, Pennsylvania.

It is recommended that adults with cancer receive appropriate vaccinations as part of standard practice, but compliance rates are low, said Dr. Denlinger. She pointed out that in 2009, only 57.8% of adult cancer survivors reported receiving an influenza vaccination, and only 48.3% reported receiving an pneumococcal vaccination.

"The NCCN guidelines recommend that all cancer survivors be considered for appropriate vaccinations," she said. They also "recommend vaccinating patients at least 3 weeks prior to the initiation of cancer treatment, if possible."

The guidelines also cover sexual dysfunction, which is a common phenomenon in cancer survivors that is often underreported and not talked about, Dr. Denlinger explained.

Sexual dysfunction, which causes distress and decreased quality of life, has been reported in up to 90% of prostate cancer survivors, 75% of rectal cancer survivors, and 50% of breast and gynecologic cancer survivors. However, she noted that few survivors report receiving information on the impact of their treatment on sexual function, and physicians often report a lack of knowledge on this topic, a lack of time to discuss it, and a lack of referral sources.

Challenges Remain

Recognizing and managing the healthcare needs of cancer survivors has become a significant responsibility of oncologists and primary care providers. However, it is not clearly defined where the responsibilities of the oncologist end and the responsibilities of the primary care provider begin.

This presents a challenge. "As therapies leave more and more long-term effects on the survivor, who is responsible for managing these effects?" she asked.

Another challenge will be how to disseminate these guidelines, which are meant not only for the oncology provider, but also for primary care and other providers who are seeing cancer survivors, she explained.

National Comprehensive Cancer Network (NCCN) 18th Annual Conference. Presented March 14, 2013.