Survivorship Issues for Patients With Lung Cancer

Christie L. Pratt Pozo, DHSc; Mary Ann A. Morgan, PhD; Jhanelle E. Gray, MD


Cancer Control. 2014;21(1):40-50. 

In This Article

Surveillance, Psychosocial Needs, and Health Promotion


Care plans that address the need for follow-up surveillance should include imaging, blood tests, and clinic visits, all of which should occur annually for patients with lung cancer who are further than 5 years from the time of diagnosis. Patients should be instructed to call their provider if symptoms occur (Table 2), and they should also be provided with recommendations for healthy behaviors that address smoking cessation, if appropriate, as well as physical activity and interventions specific for them.[16,28,29] Patients with lung cancer may need oxygen or pulmonary rehabilitation to improve or to optimize their functioning. Their psychological distress/depression should be assessed with appropriate referrals made and assistance with social services if caregiver/financial services are needed.[20,28] Interventions that recognize the value of physical activity, nutrition, and the adoption of healthy behaviors may also be important in survivorship care planning.[10] A list of such resources is shown in Table 3.

Psychosocial Needs

The Commission on Cancer psychosocial distress screening standard requires that distress be addressed at pivotal visits, such as acute diagnosis or transitions when distress may be highest so that appropriate supportive care, referrals, or both can be made. Utilization of a distress thermometer serves as a quick screening instrument that can be completed by the patient at these pivotal visits.[70] Research indicates that when QOL assessments and psychosocial concerns are addressed on an ongoing basis, outcomes can be positively affected.[71,72]

Health Promotion

Smoking Cessation Smoking is the primary risk factor for the development of lung cancer.[73] A growing body of evidence suggests that continued smoking by patients after a lung cancer diagnosis is linked with less effective treatments and a greater risk of dying.[74] With improved cancer treatments and earlier detection, smoking cessation is increasingly important and is an integral part of lung cancer survivorship care.[74] Quitting smoking has significant positive effects: decreased risk of cancer and comorbidities, increased survival time, decreased postoperative complications, increased efficacy of chemotherapy, decreased complications from radiation therapy, and overall improved QOL with improved psychological well-being and self-esteem.[74,75] Patients with lung cancer who have successfully accomplished smoking cessation report decreased fatigue and shortness of breath, as well as an increased physical activity level and improved appetite, sleep, and mood.[36]

Clinicians may be reluctant to counsel patients due to the belief that it may too late, and they may have concerns about patient feelings of stigma, selfblame, and coping skills.[74] Smoking cessation should be addressed at every visit, with support offered to enable patients to quit. Among patients with lung cancer who were current smokers at the time of diagnosis, 44% were able to quit smoking; of those who continued to smoke, only 62% had smoking cessation addressed in their clinic visit.[76] An excellent resource for health care professionals that provides pharmacotherapy information for smoking cessation treatment is Rx for Change, which is sponsored and maintained by the University of California, San Francisco School of Pharmacy.[74] Guidelines are available to help clinicians counsel patients, including the five As — Ask, Assess, Advise, Assist, and Arrange — with specific adaptations for patients with lung cancer also available.[74] ASCO has a tobacco cessation and control Web site with resources for providers and patient education material, including coverage for patient services with insurance (Table 1). Family members should also be assessed because smoke-free homes and social support can affect relapse.[74] Survivorship care should offer full support and tobacco dependence treatment tailored to the specific needs of patients.[74]

Physical Activity: Healthy behaviors and lifestyle factors play an influential role across the continuum of care. The benefit of physical activity is widely accepted as an important factor in primary prevention and impact; however, research indicates that moderate levels of physical activity, both during and posttreatment, are important.[77] Strong evidence suggests that a structured physical activity program woven into treatment and survivorship can improve symptom management and QOL.[77–80] Physical activity, coupled with a stress management program, is an effective intervention that may yield improvements in the QOL of patients with lung cancer undergoing treatment.[81] Physical activity is an effective intervention recommended for survivors beyond active treatment.[14] Research indicates that a significant association exists between levels of physical activity, QOL, and symptom management among long-term lung cancer survivors.[78] Lung cancer survivors who engage in regular physical activity have reported a better QOL across all domains and fewer distressing symptoms, as reported in reduced pain severity, decreased shortness of breath, less fatigue, and decreased frequency of both dry- and phlegm-producing cough when compared with sedentary long-term survivors.[78]

Although a lung cancer diagnosis and its related treatment may adversely affect functional ability, survivors may still benefit from some modified level of physical activity. Physical activity may benefit all subgroups of patients with lung cancer. Those with limited functional ability and poorer pulmonary function may benefit from interventions that encompass lower-intensity physical activity.[80] Patients who have anemia, compromised immune function, severe fatigue, indwelling catheters, neuropathies, and multiple and uncontrolled comorbidities will need specific precautions and directions.[82,83] Systematic reviews recommend that some level of physical activity may improve QOL even in patients with advanced cancer, but the activity level should be individualized to each patient's physical abilities.[83] Based on the evidence that physical activity has multiple benefits for survivors of cancer, health care professionals and patients should work together to explore the integration of exercise into the posttreatment care of lung cancer.

Nutrition: In general, cancer survivors should try to consume plant-based foods with at least 5 servings a day of a variety of colorful vegetables and fruits. In addition, survivors should choose foods that contain whole grains (eg, breads, brown rice, whole wheat pastas). Other guidelines recommend limiting processed and red meat and encourage diets with poultry and fish, while avoiding high-fat foods or preparations using high-fat products/methods.[83] Supplements are generally not recommended because important minerals and nutrients can usually be derived from eating a healthy, balanced diet.[83]