By 2040, there will be an estimated 26 million cancer survivors in the United States. The essential components of survivorship care are (1) surveillance for cancer recurrence, (2) surveillance for new primary cancers, (3) management of physical and psychological long-term effects of treatment, (4) prevention or mitigation of late treatment effects, and (5) coordination of care between the oncology team and primary care clinicians. Recommendations for surveillance to detect recurrence vary with cancer type and stage at diagnosis. Screening for new primary cancers is the same as for the general population. Although many cancer survivors do not undergo recommended surveillance or screening, family physicians can encourage and facilitate adherence. Family physicians should also monitor and manage the physical and psychological effects of cancer diagnosis and treatment, such as depression, lymphedema, pain, and sexual dysfunction. Cardiovascular disease is a leading cause of death for cancer survivors, often as a long-term effect of cancer treatments. Clinicians should counsel patients on cessation of tobacco and alcohol use, participation in recommended levels of physical activity, and adherence to optimal nutrition recommendations. Finally, family physicians should work with the cancer care team to coordinate the care plan and assure that all recommended components are achieved. Written survivorship care plans should be provided to cancer survivors to help them transition from active treatment to posttreatment monitoring.
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By 2040, an estimated 26 million people living in the United States will have a current or previous cancer diagnosis.1 People with cancer are considered survivors from the moment of diagnosis through end-of-life care. Although cancer survival continues to improve, significant disparities exist across race and ethnicity, with a higher risk of death from subsequent cancer in Black and Hispanic populations than in non-Hispanic White populations.2
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
The term cancer survivor has various definitions. Most commonly, it refers to any person who has a cancer diagnosis, starting at the time of diagnosis and continuing through treatment, periods of cancer-free survival, and end-of-life care. Table 1 shows the most common cancer types among female and male survivors, and eFigure A shows the percentage of cancer survivors by the number of years since diagnosis for these cancer types.3
The National Academy of Medicine (formerly the Institute of Medicine) has identified five essential components of survivorship care. They are (1) surveillance for cancer recurrence, (2) surveillance for new primary cancers, (3) management of physical and psychological long-term effects of treatment, (4) prevention or mitigation of late treatment effects, and (5) coordination of care between the oncology team and primary care clinicians.4
The American Academy of Family Physicians supports the National Academy of Medicine's report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, to emphasize the role of family physicians in all stages of cancer care.5 Primary care visits provide an opportunity to implement the components of survivorship care. Studies indicate that care from primary care clinicians is effective and leads to similar levels of quality of life and patient satisfaction as care from other clinicians.6,7 However, there are differences among family physicians in their understanding of what their role should be when caring for cancer survivors.8
SURVEILLANCE FOR CANCER RECURRENCE
Following treatment of a primary cancer, survivors require monitoring for recurrence or metastasis of the primary cancer. The timing and patterns of recurrence vary by cancer type and stage at diagnosis. Thus, recommendations for surveillance also vary.
Table 2 includes surveillance recommendations for patients who have completed primary cancer treatment and are assumed to be disease-free.3,9,10 These recommendations do not apply to patients with Stage IV cancer or metastatic disease. In addition, the National Comprehensive Cancer Network has comprehensive treatment, surveillance, and survivorship guidelines and algorithms for common cancers to assist physicians with screening and follow-up strategies.10
TABLE 2. Surveillance Recommendations for Recurrence in Cancer Survivors
| Cancer type | Recommended surveillance |
|---|---|
| Breast | History and physical examination quarterly for 5 years, then annually Mammography annually |
| Prostate | Active surveillance with no treatment PSA test no more than every 6 months DRE and prostate biopsy no more than every 12 months Monitoring after treatment PSA test every 6 to 12 months for 5 years DRE annually; can exclude if PSA is undetectable |
| Cutaneous melanoma | Stage 0 (melanoma in situ) History and physical examination (with emphasis on skin) at least annually Stage IA to IIA History and physical examination every 6 to 12 months for 5 years, then annually when indicated Stage IIB and higher History and physical examination every 3 to 6 months for 2 years, then 3 to 13 months for 3 years, then annually when indicated Imaging to investigate specific signs or symptoms (e.g., consider chest radiography, CT, or PET/CT every 4 to 12 months; consider annual brain magnetic resonance imaging) |
| Colorectal | Stage I Colonoscopy 1 year after surgery; if advanced adenoma, repeat in 1 year; if not, repeat in 3 years, then every 5 years Stage II, III History and physical examination every 3 to 6 months for 2 years, then every 6 months to 1 year for a total of 5 years CEA every 2 to 6 months for 2 years, then every 6 months for a total of 5 years Chest/abdominal/pelvic CT every 6 to 12 months from date of surgery for a total of 5 years Colonoscopy 1 year after surgery (exception: if preoperative colonoscopy was not performed due to an obstructing lesion, perform colonoscopy in 3 to 6 months); if advanced adenoma, repeat in 1 year; if not, repeat in 3 years, then every 5 years PET/CT scan not indicated |
| Uterine | Physical examination (including pelvic) every 3 to 6 months for 2 to 3 years, then every 6 to 12 months up to year 5, then annually Cancer antigen 125 if initially elevated Imaging if symptoms or findings are suspicious for recurrence |
| Thyroid | Follicular, Hürthle cell, or papillary Clinical evaluation with TSH, Tg, and anti-Tg antibody tests at 6 and 12 months, then annually Neck ultrasonography every 6 months for 1 to 2 years, then annually If using radioactive iodine treatment, obtain ultrasensitive Tg test If high risk/previous metastasis, consider TSH-stimulated whole-body radioiodine imaging Medullary Serum calcitonin and CEA test every 6 to 12 months If multiple endocrine neoplasia 2A or 2B, perform urine or plasma metanephrine and plasma parathyroid hormone tests annually |
| Urinary bladder, nonmuscle invasive | Abdominal/pelvic baseline imaging in first year for all; additional for high risk if clinically indicated Upper urinary tract baseline imaging in the first year for all; if high risk, also at year 1, then every 1 to 2 years up to year 10 Cystoscopy Low risk: at 3 and 12 months, then annually to year 5 Intermediate risk: at 3, 6, and 12 months, then every 6 months to year 2, then annually to year 5 High risk: every 3 months in year 1, then every 6 months to year 5, then annually to year 10 Urine cytology (high risk only) every 3 months in year 1, then every 6 months to year 5, then annually to year 10 |
| Non-Hodgkin lymphoma | Varies based on type, trends toward less frequent imaging |
CEA = carcinoembryonic antigen; CT = computed tomography; DRE = digital rectal examination; PET = positron emission tomography; PSA = prostate-specific antigen; Tg = thyroglobulin; TSH = thyroid-stimulating hormone.
Adherence to recommended surveillance for recurrence is often suboptimal. In a study of breast cancer survivors, 80% had mammograms during the first year after treatment, but the percentage declined significantly over time.11 In a cohort of 9,426 colorectal cancer survivors, only 17.1% received recommended follow-up and surveillance.12
Tests to evaluate for metastatic disease should not be performed in most asymptomatic cancer survivors. A cohort study of adult cancer patients, however, reported that 65% of 6,205 patients with breast cancer and 73% of 2,267 patients with colorectal cancer who were treated with curative intent received testing for metastatic disease that was not recommended in guidelines.13
SURVEILLANCE FOR NEW PRIMARY CANCERS
Along with an increased risk of recurrence, survivors are often at increased risk of new primary cancers. Nearly 1 in 12 cancer survivors develop a new primary cancer, with more than one-half dying from it.14 Lung cancers were the most common new primary cancer in a retrospective cohort study of 1.54 million cancer survivors (mean age = 60.4 years; 48% women). These cancers accounted for 19% of new primary cancers and had the highest mortality rates for both males and females.2
Reasons that cancer survivors may be at higher risk of developing a new primary cancer include tobacco use, excessive alcohol use, genetics, and effects of chemotherapy or radiation treatments. To potentially reduce some of these risks, clinicians should encourage lifestyle interventions such as counseling on tobacco cessation, limiting alcohol use, and implementing a healthy diet and physical activity.2,15
Despite this increased risk, there are limited recommendations for new primary cancer screening. Screening decisions should be made in collaboration with the patient's primary oncologist.
Specific Screening Recommendations
The Radiological Society of North America recommends that those who underwent chest radiotherapy or mantle radiotherapy (the latter was used in the past to deliver radiation to a large area of the neck, chest, and armpits) of 30 Gy or greater before 25 years of age be screened for breast cancer (if assigned female at birth). This should include magnetic resonance imaging and mammography annually, starting at 25 years of age or 8 years after completing radiation treatment.16 Guidelines from the Children's Oncology Group recommend that patients who underwent abdominal/pelvic radiation of 20 Gy or greater before 30 years of age be screened for colorectal cancer starting at 30 years of age or 5 years after completion of radiation, whichever occurs later.17
General Screening Recommendations
In addition, clinicians should ensure that cancer survivors are up-to-date with cancer screenings appropriate for their age and sex.2,15 If not part of the initial cancer evaluation, clinicians should inquire about family history of cancer and, if present, consider referral for genetic evaluation and testing.
PHYSICAL AND PSYCHOLOGICAL LONG-TERM EFFECTS
As the number of long-term (more than 5 years) cancer survivors increases, their continued health problems and needs must be addressed. All cancer survivors should be regularly assessed for psychological and physical effects of their cancer and its treatment.
Common long-term and late effects of cancer and its treatment include anxiety/depression (29%),9 pain/neuropathy (20% to 50%),18 lymphedema (20% 2 years postdiagnosis and 24% 7 years postdiagnosis),19 and sexual dissatisfaction (31% for men and 18% for women).20 In one survey, less than one-half of survivors said their health care team was very helpful in addressing common adverse effects, especially memory loss and cognitive issues, insomnia or sleeplessness, and sexual concerns.21 Family physicians caring for cancer survivors should ask about these issues and offer evaluation, treatment, and monitoring. Table 3 outlines common effects of cancer and cancer treatment, with management strategies for primary care physicians.9
TABLE 3. Long-Term Psychosocial and Physical Effects From Cancer and Cancer Treatment
| Effect | Recommendations and comments | Management options |
|---|---|---|
| Anxiety, depression, posttraumatic stress disorder | Survivors of cancer and its treatment are at increased risk of mental health issues (e.g., fear of recurrence, anxiety, depression) that can persist for many years Monitor for signs and symptoms of distress, especially at times of new diagnoses, transitions of care, cancer surveillance, significant loss, other major life events, and social isolation Use evidence-based screening questions (Patient Health Questionnaire-9, General Anxiety Disorder-7) at preventive visits, when there is a change in clinical status or treatment, or the patient presents with multiple somatic symptoms | Treatment of contributing factors (e.g., pain, sleep disturbance, fatigue, medical comorbidities, substance use disorder) Referral to a therapist with psycho-oncology training if possible SSRI or SNRI as first-line treatment If appropriate, consider use of benzodiazepines for acute anxiety relief or while waiting for antidepressant to take effect |
| Cognitive decline | There is no effective brief screening tool for cancer-associated cognitive dysfunction Existing tools (such as the Mini-Mental State Examination) do not strongly correlate with patient reports of cognitive dysfunction Patients who report cognitive impairment should be screened for potentially reversible contributing factors (e.g., sleep disturbances, depression, fatigue) | Neuropsychological evaluation/testing Cognitive rehabilitation with occupational therapy, speech therapy, neuropsychology Psychotherapy |
| Fatigue | Chemotherapy and radiation are predisposing factors for cancer-related fatigue; however, fatigue may occur with surgery alone The course of fatigue varies but can be disruptive for months or years after treatment is complete | Treatment of contributing factors (e.g., medication adverse effects, pain, emotional distress, anemia, vitamin deficiency, sleep disturbance) Maintaining adequate levels of physical activity |
| Fertility | Discuss treatment-associated infertility as needed For survivors of breast cancer, pregnancy is considered safe; the hormonal environment of pregnancy is not thought to increase the risk of recurrence | Referral to reproductive specialist |
| Hormone-related symptoms | Many survivors experience symptoms regardless of ovarian function Serum estradiol levels can confirm menopausal status in survivors who have had chemotherapy or pelvic radiation exposure, or who are using tamoxifen Hormonal therapies are contraindicated for survivors of hormonally mediated cancers and should be used with caution in those with increased genetic risk | Treatment of vasomotor symptoms Pharmacologic SNRI (venlafaxine, desvenlafaxine [Pristiq]) SSRI (sertraline, paroxetine, fluoxetine) Anticonvulsant (gabapentin, pregabalin [Lyrica]) Alpha agonist (clonidine) Nonpharmacologic Acupuncture CBT Exercise/physical activity Weight loss if needed |
| Lymphedema | Swelling occurs in limbs or other areas (neck, trunk, genitals) due to lymph fluid accumulating in interstitial tissue Common adverse effect of cancer treatment, usually occurs on the same side of the body as the treatment | Referral to certified lymphedema therapist (if available) Compression stockings Progressive resistance training under supervision Physical therapy for range-of-motion exercises Referral to a lymphedema surgeon (selected patients) |
| Pain | Complete a comprehensive pain assessment to determine the etiology Discuss with patient/caregivers realistic treatment goals, functional improvement, and medication adverse effects Psychological support for chronic pain is necessary, with consideration of referral for psychosocial services for those in distress When opiates are appropriate and necessary, establish treatment goals and use the lowest effective dose for the shortest period possible; consider prescribing naloxone and educate the patient/caregivers on use | Pharmacologic Acetaminophen Nonsteroidal anti-inflammatory drugs Cyclooxygenase-2 inhibitors SNRI Muscle relaxants Topical ointments/patches (lidocaine, capsaicin) Nonpharmacologic CBT and psychosocial support Physical modalities (heat, ice, acupuncture, transcutaneous electrical nerve stimulation) Physical activity |
| Sexual health | Discuss sexual health and any related distress as part of a comprehensive whole-person approach to care | Pelvic physical therapy For vaginal dryness: topical therapies For erectile dysfunction: oral phosphodiesterase inhibitors as needed, if not contraindicated |
CBT = cognitive behavior therapy; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.
Information from reference 9.
Additionally, some patients experience financial hardship associated with their cancer treatment. Clinicians should inquire about financial difficulties and refer patients to local social workers, case managers, and other support services as needed.
PREVENTING OR MITIGATING LATE EFFECTS OF TREATMENT
Cardiovascular disease is a leading cause of non–cancer-related death in cancer survivors. Adult survivors of childhood cancer and those with adult-onset cancers have an increased risk of cardiovascular disease, independent of well-known risk factors such as hypertension, hyperlipidemia, and diabetes mellitus.22
Risk factors specific to cancer survivors include use of chemotherapy agents (especially anthracycline drugs, which can result in heart failure), radiation exposure to the chest, inflammatory and oxidative effects of cancer, and biologic predispositions. Table 4 outlines ways to optimize cardiovascular health for cancer survivors, including lifestyle changes similar to those recommended for the general population.23
TABLE 4. ABCDEs to Promote Cardiovascular Wellness in Cancer Survivors
| A | Awareness of risks and presentation of heart disease |
| Assessment of cardiovascular disease and cardiovascular risk | |
| Aspirin use as appropriate (indicated for secondary prevention; clinician-survivor discussion required for primary prevention with careful weighing of benefits and risks) | |
| B | Blood pressure monitoring/management (with clinician-survivor discussion regarding the use of antihypertension treatment and blood pressure goals) |
| C | Cholesterol assessment/management (with clinician-survivor discussion regarding use of statin therapy for primary prevention and lipid profile goals) |
| Cigarette/tobacco cessation | |
| D | Diet and weight management |
| Dose (cumulative) of anthracyclines, and/or radiation to the heart | |
| Diabetes mellitus prevention/treatment | |
| E | Exercise |
| Echocardiogram or EKG based on risk |
Reprinted with permission from Denlinger CS, Sanft T, Moslehi JJ, et al. NCCN guidelines insights: survivorship, version 2.2020. J Natl Compr Canc Netw. 2020;18(8):1020.
Tobacco and Alcohol Use
Reduction or cessation of tobacco and alcohol use reduces the rates and recurrence of some cancers and improves overall health outcomes.24,25 Family physicians should counsel patients to avoid smoking, treat nicotine dependence with available pharmacotherapy, and refer for cessation counseling and additional resources to assist patients in quitting.25,26 Patients should also be advised to avoid or limit alcohol consumption.24
Skin Cancer Prevention
Patients with a history of skin cancer should use sun protection, including use of sunscreen (minimum of sun protection factor [SPF] 30) and physical barriers whenever possible.
Physical Activity
Aerobic exercise, strength training, and yoga have positive impacts on pain, mood disorders, fatigue, and cognitive functioning.27–29 Family physicians should counsel cancer survivors to avoid inactivity and recommend specific minimum exercise goals. A combination of cardiovascular exercise (150 to 300 minutes at moderate intensity or 75 to 150 minutes at vigorous intensity weekly) plus 2 days per week of strength training for major muscle groups is recommended.30–32
Exercise recommendations must be tailored to the individual's comorbidities and functional status, with modifications based on cancer treatment complications, such as lymphedema, peripheral neuropathy, and bone loss.33 For example, physicians can advise patients to avoid uneven surfaces if they have a history of neuropathy, avoid public gyms when receiving immunosuppressive therapy, and take frequent breaks if experiencing excessive fatigue.
Nutrition
Although the optimal nutritional and dietary patterns are uncertain, consistent data support adopting a plant-focused diet (rich in fruits, vegetables, legumes, whole grains, and fiber) and limiting saturated fats, red meats, and processed foods for better overall health and reduced risk of cancer.34–38
These general nutrition principles should be applied to cancer survivors, with customization that will provide adequate nutrition to support the individual's overall health.36 Dietary patterns may be informed by geographic location, cultural influences, and the patient's preferences and health-related goals, such as weight management.39
Historically, there has been concern that phytoestrogens (estrogenic isoflavones) in soy products (e.g., soy beans, soy milk, tofu) may lead to an increased risk of breast cancer development or recurrence based on in vitro and animal studies.40 However, more recent literature suggests that moderate consumption of soy products is beneficial in promoting overall health and survival, with the strongest evidence for reduction of breast cancer recurrence and prevention of primary lung cancer.31,41
CARE COORDINATION
Overseeing Surveillance
Ideally, family physicians will be partners with patients during their journey from cancer diagnosis through staging, treatment, and ongoing monitoring. Family physicians are uniquely positioned to oversee a coordinated care plan for cancer survivors.9 They can help assure that patients are seen by members of the cancer care team at the appropriate intervals to receive recommended surveillance.
Survivorship Care Plan
A written survivorship care plan is a communication tool to help the patient transition from active treatment to posttreatment monitoring. The plan should include a summary of past and future treatments and specific recommendations for monitoring. These plans are recommended by multiple organizations,4,32 although they have limited evidence of effectiveness in the real-world setting, potentially due to barriers with implementation and ineffective design.42
Communication
In addition to following a survivorship care plan, family physicians should maintain communication with oncologists and other members of the care team. Specifically, the roles of specialists and family physicians in monitoring for recurrence, screening for new primary cancers, and managing expected sequelae from treatment should be clear.
Health professionals such as physical therapists, dietitians, social workers, and patient navigators can be part of the team by helping assess for individual and community-level barriers to meeting lifestyle recommendations and supporting patients in overcoming challenges throughout the continuum of survivorship care.
This article updates previous articles on this topic by Wilbur43 and Sunga, et al.44
Data Sources: Sources searched include PubMed, the Cochrane Database, National Comprehensive Cancer Network, Agency for Healthcare Research and Quality, UpToDate, and Essential Evidence Plus. Search terms included cancer survivor, survivorship, surveillance, follow-up, breast cancer, prostate cancer, colorectal cancer, uterine cancer, non-Hodgkin’s lymphoma, thyroid cancer, melanoma, and lifestyle. Search dates: August and October 2023, and May 2024.
