New paradigms in planning cancer rehabilitation and survivorship

Research on the psychosocial aspects of cancer and practice to counteract those effects are no longer addenda to clinical work and research in oncology. The opening up of research into rehabilitation, late effects and the entire concept of survivorship [1] has extended the concept of cancer [2]. Gone are the days when psychological support was claimed to prolong the life of cancer survivors [3]; the claim has little credence, and the data do not support it [4]. Research on survivorship has followed much more productive alleys, leading to studies on co-morbidity, the prevention, detection and treatment of late effects, their timing and the effective elements of rehabilitation for cancer patients [5]. Authorities such as the Institute of Medicine [6] and the National Comprehensive Cancer Network [7] in the USA, the World Cancer Report [8] and numerous other national and international organizations and publications [9] concur that cancer survivors require interventions, not only pharmaceutically and with narrow tumor-oriented treatment, but also treatment of the person experiencing cancer. A person with a spouse has to discover how to restore marital life [10], a cancer survivor may lose her or his job [11], and daily care is needed for the symptoms and other problems that are late effects of cancer treatment [12]. In the European Union, the number of cancer survivors was estimated to be 17.8 million in 2008 [13], and this number is growing. Therefore, public health policies are needed to defi ne and direct services to these survivors, many of whom will become part of the population of long-term survivors. Unlike cancer patients in earlier times, those who survive today may not only have had a cancer but often have one, two and more concurrent chronic diseases, such as diabetes, cardiovascular disease or thyroid dysfunction. Integrated treatment decisions and management structures are required for these more complex cases. The specialization of medical services over the past 50 years benefi ts patients by ensuring the availability of expertise but tends to leave integration of treatment in a ‘ no man ’ s land ’ . Integration of treatment will be essential in the decades to come, especially with the advent of more targeted, individualized treatment trajectories for each cancer patient. The ‘ one size fi ts all ’ approach must give way to assessment and management of individual tumor burden, co-morbidity and perhaps even the patient ’ s own preferences. These factors call for a shift in our caring culture, to a focus on recovery, coping with late effects and self-management. In principle, a public health system works on the basis that citizens take care of themselves and contact the health system if they recognize symptoms; at that point, citizens expect proper action by the health system. This balance between self-management and rapid health system action in the case of symptoms works for citizens who are healthy and are not chronically ill. For such survivors, including those who survive after treatment for cancer, public health systems have instituted a time-consuming, expensive, labor-intensive follow-up system, the function of which is now being questioned. The aim of this huge follow-up program, which involves millions of encounters between cancer survivors and specialists across Europe, is the detection of recurrence and secondary cancer. Concern has been raised, however, that these large programs are draining too many resources from the core activity of specialized clinicians. Nurse practitioners in several cancer hospitals in the USA are qualifi ed to perform most follow-up activities, including referrals and prescriptions for the management of late effects of cancer treatment, under the supervision of Acta Oncologica, 2013; 52: 191–194