Survivorship in new harbors

Acta Oncologica was once again main sponsor for the European Cancer Rehabilitation and Survivorship Symposium (ECRS) in Copenhagen September 2016. The three preceding symposia were held in 2010, 2012 and 2014 [see 1–11]. In 2016, some 350 clinicians, scientists and people working in the area provided knowledge about the growing field of cancer survivorship. We also organized workshops with more than 100 participants and used this forum for exchange of clinical practice and development of the scientific methods we apply when studying cancer survivors. Developments in demography and medical advancement challenge our health care models. Health care systems are constantly challenged by patient demands, budget restrictions, implementation of new equipment and overall demographic changes with an aging population. This contributes to a continuous integrative maneuver to establish a well-functioning everyday work place and not the least – institutions that address the needs of the patients with high-quality care. In the horizon, we realize the changing demographic landscape with more patients having more than one disease over a life span. The number of diseases on the death certificate will probably increase by one or two per generation, expecting a person born in this decade to die with 4–6 chronic disorders. Chronicity becomes an everyday phenomenon, which disputes the whole concept of cancer as a single disease. Cancer patients are no longer only cancer patients; they have become diseased citizens and cancer is only one out of several biological realities, which affect the physiology, the social life, and psychology. Cardiovascular diseases, endocrine disorders, musculoskeletal or neurodegenerative diseases become concurrent conditions competing between each other when deciding, which therapy the patient has to comply with. This calls for development of new algorithms, with personalized medicine targeting the cancer as well as the concurrent diseases. Do we expect cancer patients to be in gene-specific treatment for their cancer and do we then imagine that these patients also are in gene-specific treatment for their specific genetic variant of, e.g., hypertension? This situation is close, but yet far away, and points to the need for integrated treatment plans and integration of specialties that the medical profession has used decades to establish as independent entities. Now it is time to reunite the medical specialties for the sake of integrated treatment. We have reached a point where our old ideas about division of knowledge between specialties simply does not work. Our current model applies to cancer as a single disease. The new model has to apply to the citizens taking into account the entire list of diseases and drugs or other modalities used for the treatment of these diseases. Our sequential model of cancer care is also challenged. We have developed and refined a diagnostic system including decision on treatment options followed by a treatment period and later rehabilitation. Often the treatment results in late effects, which in time also require treatment. It is a model, which assigns responsibility between authorities and balances between public or private institutions depending on the organization of the health care system in each country. Still, everywhere we look, the model is sequential. This approach needs rethinking. Why not prevent acute symptoms and perhaps even the late effects or at least reduce their severity? Why not initiate rehabilitation at date of diagnosis as this, in principle may relieve the total symptom burden in the patients with cancer? Small, however, extremely interesting and promising randomized trials have shown that the cancer patients undergoing surgery may benefit in terms of their postoperative physiological and psychological outcome if a certain time period is spend to prepare and optimize the health of the patient. If the physical condition is optimized it may facilitate that the surgery is not followed by unwanted physical side effects related to the surgery. Alongside, it may also have a psychological effect, which the patient may benefit from in coping with the cancer diagnosis and its treatment. The psychological effect may go through the potential empowerment of the patient. Instead of sitting at home, ruminating over the diagnosis and the changed perspectives of life, waiting for the surgery, we actually hand back some options for patients to influence the cancer trajectory. In popular terms, we are promoting that the patient may become ‘an editor of his own life’. The loss of control, the distress, anxiety and depression, which often follows a cancer diagnosis, may then be tackled. Not completely, but partly by assigning some tasks to the patient in the time between diagnosis and first treatment. We may even argue that this time-period should be prolonged, at least for some cancers, such as breast cancers, prostate and colorectal cancers. By rethinking the model, we may take on