Survivorship care planning: unique opportunity to champion integrative oncology?

Already numbering 13.7 million and growing rapidly, cancer survivors have taught us two important lessons. First, even when cancer treatment ends, the cancer experience does not. Rather, the transition from active treatment to recovery ushers in a whole new period in the cancer journey, often referred to as survivorship (1). The second lesson learned, a corollary to the first, is that cancer and its treatment have the capacity to affect not simply physical well-being, but also virtually every aspect of an individual’s life, including psychological, social, economic and existential health and function. While some of these effects (eg, alopecia, nausea, and vomiting) dissipate rapidly once treatment ends, others (eg, fatigue, sexual dysfunction, memory problems) can persist over time, in some cases (eg, lymphedema, pain syndromes), becoming chronic. Still another set of effects may appear months or years after treatment ends (cardiac dysfunction, osteoporosis, diabetes), the most worrisome of these being recurrent or second cancers (1). Today, most oncology practitioners recognize the need to consider cancer’s long-term impact on their patients’ overall health and function. However, how best to do this remains a challenge (2). The evolving mandate to develop survivorship care plans, inclusive of plans to address psychosocial needs and provision of counsel about health promotion, presents a unique opportunity for advancing an integrative model of cancer care for those entering this new phase. Cancer survivors are already employing a menu of complementary and alternative medicine (CAM) practices to manage the chronic effects of treatment, reduce the risk of recurrence or second cancers, gain control over their lives, address comorbid conditions exacerbated by illness, and, ultimately, improve their quality of life. Population-based studies report usage rates ranging from 65% (ever used) to 40% (used in the past year) (3); and data suggest rates are not diminishing over time (4). Within the spectrum of treating the lingering and late effects of cancer, some promising interventions are emerging. For example, ginseng and yoga have shown promise in symptom management trials of fatigue and sleep disturbances respectively, both chronic problems reported frequently by cancer survivors (5,6). Given the documented positive association between quality of life and survival, there is arguably an important role for CAM use in recovery and life after cancer. Many of the challenges in conducting CAM research among survivors are not unique to the field. As with any intervention trial, issues of quality control, standardization, as well as understanding how the treatment might interact with adjuvant or maintenance therapies, which for growing numbers of cancer survivors may be ongoing years after curative therapy ends, must all be adequately addressed. Mind-body therapies, such as yoga and tai chi, also face challenges similar to the more conventional cognitive-behavioral therapies, with respect to selecting an appropriate control arm, maintenance of treatment fidelity, and participant adherence. To date, few treatment centers or clinics provide systematic orientation to CAM therapies, and many survivors still do not ask about the utility of these in managing their long-term health and function. In addition, opportunities to implement an integrative model of care must be carefully balanced against what is known to be safe and effective. Unfortunately, data are lacking on what practice to recommend to whom and for what, or the safety, mechanism of effect and efficacy of many CAM interventions to address troublesome posttreatment concerns. Further, there is no evidence to suggest that specific CAM practices may positively or negatively affect recurrence or prevent new cancers. More research, both descriptive and interventional, is needed if we are to remedy this situation and promote a model of posttreatment care that embraces care for the whole patient.