Addressing the Needs of Cancer Survivors: An Emerging Global Challenge

Guest student blog by Matthew J. To, BMSc candidate,  Schulich School of Medicine and Dentistry, The University of Western Ontario (email mto3@uwo.ca)

This past summer, I worked as a research student at a new cancer survivorship research centre, one of the first of its kind in Canada [1]. It was through working at the centre that I came to realize the enormous challenge that the global community is faced with in addressing the needs of cancer survivors. In this piece, I hope to share some of the things I learned through my work experience.

Despite the huge amount of cancer research that is being conducted worldwide, it is clear that this disease or rather, this set of diseases, will be sticking around for a while [2]. With the ever increasing number of individuals who are diagnosed, the emerging field of cancer survivorship plays an important role in highlighting and addressing the needs of patients from the time of diagnosis to after treatment. There are over twenty-eight million cancer survivors worldwide [3]. Traditionally, a cancer survivor is someone who has been diagnosed with cancer, but this definition has been updated to include family members, friends, and caregivers of the affected individual [4]. Cancer survivorship as a field deals with a whole range of issues including but not limited to cancer-related physical and psychological issues, lifestyle after treatment such as the return-to-work transition as well as follow-up care and prevention of secondary malignancies [4].

In the past, it was not particularly clear whose responsibility it was to address issues like cancer-related fatigue after treatment. If the patient had already received the proper treatment, were they expected to approach their family physician or their oncologist? For more sensitive topics like psychosexual issues prevalent in genitourinary cancers, patients and physicians alike may have been uncomfortable in addressing the topic. However, this appears to be changing. For example, family physicians want to be more involved in managing care for patients affected by cancer and oncologists have been involved in the delivery of follow-up models which include screening for recurrence and promoting healthy lifestyles [5, 6]. Also, many non-profit organizations such as the National Coalition for Cancer Survivorship have worked tirelessly to raise awareness about the issues faced by cancer survivors and advocate for high-quality care [7].

Delivering quality survivorship care is often complicated by the fact that each type of cancer has its own unique set of subtleties that need to be addressed. For example, testicular cancer primarily affects young men between the ages of 15 to 35 and high cure rates of the disease have led to a huge increase in the number testicular cancer survivors [8, 9]. Some issues that these survivors are faced with are infertility and sexual dysfunction [10]. Managing survivorship care for this younger population of survivors would be markedly different from a disease like lung cancer which generally affects an older population. Moreover, factors such as employment status, food availability, and emphasis on spirituality differ between populations within each country and between countries. This means that countries will have to develop survivorship strategies that uniquely address the needs of their respective populations [6]. Furthermore, the aging of the oncology workforce and the increasing number of survivors worldwide presents an additional challenge [11].

Undoubtedly, individuals diagnosed with cancer will need much more than the latest surgical intervention to live healthy and happy lives. Cancer survivorship as a field seeks to address the needs of survivors with a holistic and increasingly community-engaged approach. As the global population of survivors steadily increases, more partnerships between health care professionals, research groups, and community organizations are needed to bring cancer survivorship forward in tackling the unique challenges faced by those impacted by cancer.

References

1. ELLICSR (2010) Available: http://ellicsr.ca. Accessed: 24 February 2011.

2. Downar J (2010) Cancer: it’s time to change the sign. CMAJ 182: 1588.

3. American Cancer Society (2008) Lance Armstrong Announces Global Cancer Summit. Available: http://www.cancer.org. Accessed 24 February 2011.

4. National Cancer Institute (2006) About Cancer Survivorship Research: Survivorship Definitions. Available: http://cancercontrol.cancer.gov/ocs/definitions.html. Accessed: 21 February 2011.

5. Grunfeld E (2005) Cancer survivorship: a challenge for primary care physicians. British Journal of General Practice 55: 741-742.

6. Robinson E (2010) Expert Editorial: The Global Puzzle of Survivorship: Assessing Current Standards, Gaps, Best Practices. Available: http://www.asco.org/ASCOv2/Meetings/Gastrointestinal+Cancers+Symposium/2011+Gastrointestinal+Cancers+Symposium+Daily+News/Features/Expert+Editorial:+The+Global+Puzzle+of+Survivorship:+Assessing+Current+Standards,+Gaps,+Best+Practices. Accessed: 24 February 2011.

7. National Coalition for Cancer Survivorship (2010). Available: http://www.canceradvocacy.org. Accessed: 21 February 2011.

8. Feldman DR, Bosl GJ, Sheinfeld J, Motzer RJ (2008) Medical Treatment of Advanced Testicular Cancer. JAMA 299: 672-684.

9. Gospodarowicz M (2008) Testicular cancer patients: considerations in long-term follow-up. Hematol Oncol Clin North Am 22: 245-255.

10. Arai Y, Kawakita M, Okada Y, Yoshida O (1997) Sexuality and fertility in long-term survivors of testicular cancer. Journal of Clinical Oncology 15: 1444-1448.

11. Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M (2007). Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract 3:79-86.

Competing interests: Matthew To states that he worked as a paid research student at ELLICSR (Electronic Living Laboratory for Interdisciplinary Cancer Survivorship Research).

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2 Responses to Addressing the Needs of Cancer Survivors: An Emerging Global Challenge

  1. Title-: Survivors of Cancer in Kolkata, West Bengal, India- a scenario
    Authors_:
    *Professor Pranab kumar Bhattacharya- MD(cal) Patho, FIc Path(Ind.),Presently Professor and Head, Department of Pathology, Regional Institute of Ophthalmology , The Medical college, Kolkata -73 ,W.B and Ex- Additional Professor of Department of Pathology, Institute of Post Graduate Medical Education & Research,244 AJC Bose Road, Kolkata-20, West Bengal, India** Mr. Rupak Bhattacharya-Bsc(cal), Msc(JU), 7/51 Purbapalli, Sodepur, Dist 24 Parganas(north) Kol-110,West Bengal, India **Mr.Ritwik Bhattacharya B.com(cal), **Mr Soumyak Bhattacharya MBA of residence7/51 Purbapalli, Sodepur, Dist 24 parganas(north) ,Kolkata-110,WestBengal, India*Miss Upasana Bhattacharya- Student, Mahamayatala, Garia, kol-86, only daughter of Prof.P. K Bhattacharya*** Mrs. Dalia Mukherjee BA(hons) Cal, Swamiji Road, South Habra, 24 Parganas(north) West Bengal, India***Miss Aindrila Mukherjee-Student ,Swamiji Road, South Habra, 24 Parganas(north), West Bengal, India****; Mr. Surajit Sarkar BSC DMLT, Technician Pathology, Institute of Post Graduate Medical Education & Research,244 a AJC Bose Road, Kolkata-20, West Bengal, India , Kolkata-20 Dr ****Tridibeswar Mandal MD(cal) Biochemistry IPGME&R Kol-20

    The Indian subcontinent is today home to 16.5% of the world’s population
    [ census 2011 shows it’s population increased 122 cores next to china and West Bengal it is approximately 9.6 cores ] and at any one time it is estimated that there may be not less but over 3.5 million or people with cancers in different age group from childhood to aged. Number of Cancer Patients at present in West Bengal approx. 3,50,000. Number of Cancer Patients increasing every year in West Bengal approx. 69,000. Radiotherapy needed every year for patients Approx. 60,000 when Radiotherapy capacity of West Bengal at present Approx. 22,000. Fatal consequences for want of essential treatment Approx30,000. Cancer had never been a prominent healthcare issues in kolkata , West Bengal, as per first author, compared with other diseases in West Bengal and in Kolkata. But the fact is that as a histopathologist of the city in tertiary medical colleges of the city, the first author’s last 26 years experience while diagnosing biopsies, is that various histological types of cancers, like Lung, Breast, Cervical, Neck cancer , Skin, Mouth cancer, Thyroid cancers, child hood leukemias , Lymphomas, soft tissues sarcomas are also emerging today as a significant health problem in kolkata and suburban people of West Bengal. Peculiarly Cancer patients for some unknown reasons, are most prominently found amongst low socioeconomic class people, possibly due to their diet, consumption of bidi, other form of tobacco, local made alcohol, STDs , HPV poor vitamin and antioxidants use and other habit or some kinds of genetic susceptibility and their very low financial capability for purchasing health, and pocket expenditure, access towards any three or five star hotel private health care institutions, where gadgets for advanced treatment and diagnostic facility may be available but with complete business and huge amount profit outlook and nonetheless family members illiteracy also contribute towards their advanced stages of disease on presentation to public tertiary care hospitals clinics, and due to very high cost chemotherapy, Immunotherapy, biological therapy [ Chemotherapy not only kills the patient ultimately and their family members too economically ]and most of people accepts Homeopathy, Traditional, Complementary and Alternative Medicines (TCAM) are often the only therapies available for low socioeconomic people in West Bengal , as they are less costly and in affordable reach to poor socioeconomic class of West Bengal . India has just 48-50 doctors per 100,000 people compared to the UK with 230 and the US with 256. The poor provision of public sector healthcare in cancer diagnosis and therapy in tertiary care Medical colleges means many people (even a section of the poor) turn to the private sectors cancer treatment centers, those are far distant of all kinds of human face towards the cancer and terminally ill and they understands in terms of only business and money making centers. The number of cancer patients are steadily increasing also in India due to early and improved histopathological diagnosis and improved modality of treatment facilities only for the upper class and rich class societies. The majority of Indian cancer patients present late stage incurable diseases (75% to 80%) when first diagnosed. Chemotherapy [ The authors really doubt how much the costly chemotherapy is benificial for ultimate survivors except in few histological type cancers and when diagnosed most early ] or Radiotherapy or targeted biological & immunological therapy of Cancer patients with both solid and hematological malignancy including Stem Cell Transplantation facility[in infancy] are today available in certain centers of Kolkata, West Bengal .
    Presently in India, out of a million newly diagnosed cancer patients each year, more than 60% die within 12-24 months of diagnosis and another one million cancer survivors show progressive disease within five years of diagnosis[5] The number of U.S. cancer survivors however increased from 9.8 million in 2001 to 11.7 million in 2007, according to an analysis of new cancer cases and follow-up data from NCI’s Surveillance, Epidemiology, and End Results (SEER) program published in march 11th 2011 report[6]. According to that report, it were however breast, prostate, and colorectal cancers were the most common types of cancer amongst those survivors in US, accounting for 51 percent of total cancer diagnoses in USA. In that study, among all cancer survivors, 54.3 percent were female, 45.7 percent were male, nearly 7 million were 65 years of age or older, and 4.7 million received their diagnosis 10 or more years earlier. The increase seen over the past 4 decades is attributable to a variety of factors, including an aging U.S. population, most earlier detection of cancer by CT MRI and with help of immunochemistry .PCR, Flowcytometry, expert histopathologists services and more &more sophisticated treatments that allow individuals to live longer following initial diagnosis[1] As for the incidence of gliomas is increasing worldwide, including India and in one study from West Bengal, India, in which only 7.9% of brain tumors were GBMs, while 46.8% were astrocytomas. Low grade gliomas (LGGs) typically occur in younger adults, normally before age 40, and encompass a spectrum of histological subtypes that resemble differentiated macroglial cells, without evidence of anaplasia. Diffuse astrocytomas represent 60 – 70% of the LGGs and are the most common of LGGs The subtypes of low-grade astrocytomas include fibrillary, protoplasmic, pilocytic, and gemistocytic astrocytoma. The fibrillary subtype is the most common in adults while the gemistocytic subtype is less common, but has a higher potential for anaplastic transformation. Other histological subtypes of the LGGs include the juvenile pilocytic astrocytoma (JPA), which usually occurs before age 25, oligodendroglioma/oligoastrocytoma (LGO/LGOA), ganglioglioma, pleomorphic xanthoastrocytoma (PXA), subependymal giant cell astrocytoma (SEGA), subependymomas, and desmoplastic gangliomas. Different gliomas occur in differentage groups and some entities such are PXA are more common in adolescents, while others are more common in the elderly, such as GBM[3]
    But cancer survivors must faces several health related issues, Health risks, poor mental, financial ,physical, and social and sexual Quality of life[ QOL ]that must be looked for. Of these many QOL domains, the largest disparity is often found in the area of mental health which cancer people often reported
    A] psychosocial issues- many cancer survivors complain that there are little emotional support or financial support from the government or family or relatives. Many patients even losses their services when they are detected cancer and they are severely depressed. They faces mental trauma and shock when they hear about their cancer. They fear of their recurrences of the cancer and follow up visit and further expenditure. They are afraid of severe pain. The city of kolkata so needs awareness about the disease particularly in rural and sub urban cities and there might be mobile cancer detection units from department of health and family planning west Bengal roaming at villages at free of cost but never by the private institutions Such system are non existent even in Kolkata city and a far off concept for the rural village and suburban. People spend often Rs 60,000 on a treatment at private health care institutes that can be easily undertaken for Rs 3,000 if there was government level vigilance on mush rooming private health care systems, with law and bill for extreme punishment for such malpractices with terminally ill. To combat cancer, one needs strong emotional support, from family and other cancer survivors.”
    B] in the Childhood Cancer Survivor are of median time of survivors for 14 years in one study[2] . But they are likely developing thyroid related cancers and other thyroid related problems like hypothyroidism[17%]. Radiation-related thyroid cancer doubles for every gray (Gy) of exposure to the thyroid. Radiation-related risk of thyroid cancer increased with increasing I-131 dose and was greatest for those individuals who were younger at the time of exposure. Risk appeared similar for men and women. As for example, Treatment for Hodgkin’s disease (HD) is found to be associated with a variety of thyroid abnormalities, including hypothyroidism, hyperthyroidism, and thyroid neoplasms like pappilary carcinomas
    C] the incidence rate of contra lateral breast cancer positive for the estrogen receptor (ER] We know from randomized trials that drugs like tamoxifen significantly can reduce the risk of a contra lateral breast cancer, by about 40 percent, Tyrosine inhibitors may be used with good results
    D] Skin cancer is one of the most common secondary neoplasms amongst many childhood cancer survivors. Behavioral interventions addressing lifestyle factors, including sun safety behaviors, among adolescent survivors of childhood cancer should be integrated into long-term care to reduce the risk for secondary malignancies and diseases.
    E] The incidence of major congenital birth abnormalities was slightly higher in the offspring of male cancer survivors compared with children of fathers with no history of cancer, The increasing number of male cancer survivors has given rise to concerns about the health of their offspring. Although previous studies on children conceived naturally have been reassuring about the health of the children, The researchers found that a paternal history of cancer was associated with a 17% increased relative risk of major congenital malformations
    For example in hematological malignancies, generally when treated with chemotherapy, were associated with a non-statistically significant increased risk of congenital abnormalities in children with a paternal history of cancer compared to those without, no such increased risk was seen with children with a paternal history of testicular seminoma

    Reference
    1] Kristine Crane” Offspring of Male Cancer Survivors Have Slightly Higher Risk of Congenital Birth Abnormalities” Journal of National Cancer Institute jncimedia@oxfordjournals.org 301-841-1285

    2] Charles Sklar, John Whitton, Ann Mertens, Marilyn Stovall, Daniel Green, Neyssa Marina, Brian Greffe, Suzanne Wolden and Leslie Robison “Abnormalities of the Thyroid in Survivors of Hodgkin’s Disease: Data from the Childhood Cancer Survivor Study “The Journal of Clinical Endocrinology & Metabolism Vol. 85, No. 9 3227-3232 doi:10.1210/jc.85.9.3227
    3] Khan MK, Hunter GK, Vogelbaum M, Suh JH, Chao ST “Evidence-based adjuvant therapy for gliomas: Current concepts and newer developments” Indian Journal of Cancer Vol. 46, No. 2, April-June, 2009, pp. 96-107
    4] Mays D, Black JD, Mosher RB, Shad AT, Tercyak KP
    Improving short-term sun safety practices among adolescent survivors of childhood cancer: a randomized controlled efficacy trial. [JOURNAL ARTICLE] J Cancer Surviv 2011 Feb 27

    5] Alex Broom, KR Nayar,Philip Tovey,Rashmi Shirali, Rakesh Thakur, Tulika Seth, Prem Chhetri Indian Cancer Patients’ use of Traditional, Complementary and Alternative Medicine (TCAM) and delays in presentation to Hospital OMJ. 24, 103-107 (2009); doi:10.5001/omj.2009.24

    6] U.S. Cancer Survivors Increase to Nearly 12 Million- National cancer Institute Bulletin-A trusted source for cancer research bulletin- cancer research Highlights March 11,2011 Morbidity and Mortality Weekly Report.

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