Surviving cancer starts at its diagnosis

When considering cancer survivorship, it's very important to define it from day one. It doesn't start when patients have received all their treatments, or when they have no active disease.

In the United States, we have a large and growing number of patients who are cancer survivors, and these numbers are only expected to rise. For early-stage disease, during the first five years of treatment through follow-up, visits usually take place in the oncology clinic. But after five years, patients graduate or are discharged from the oncology clinic and return to primary care or internal medicine clinics, a new transition thanks to significantly improved survivorship rates and innovative treatments.

When patients return to internal medicine, it's important to understand several things. First, what are the long-lasting effects of cancer therapies? These can be the effects of radiation like shortness of breath due to pulmonary fibrosis or other malignancies after radiation. What are the consequences of the side effects of surgeries? How do they affect the patient's mobility? If the patient had a full amputation, how can we ask this patient to increase physical activity? How will treatments affect other comorbidities?

Consider the very long-lasting effects of chemotherapy. A very well-known one, particularly in breast, prostate, or lung cancer, is neuropathy. Patients might have long-lasting neuropathy that requires the assistance of internal medicine after they have been discharged from oncology. As we develop new therapies, particularly immune checkpoint inhibitors, or immunotherapy, these drugs have very permanent side effects to keep in mind, particularly endocrinopathies. This is something that the internal medicine doctors will need to follow up with. The first approval of immunotherapy dates to 2015, so we don't even have 10 years with these drugs. Side effects include hypothyroidism, which is very common, and in patients who have immunotherapy, it's irreversible. So there is a need to monitor the thyroid function. Furthermore, even after discontinuation of immunotherapy, patients can experience adverse events affecting their endocrine system, lungs, and joints.

We need to remember that cancer screening doesn't stop when a patient gets diagnosed with cancer. In fact, it is even more important afterward, because chemotherapy and radiation are risk factors for secondary malignancies. This is common, unfortunately, when patients survive the first cancer and then they get a second cancer. A previous diagnosis of cancer doesn't eliminate the importance of future cancer screening with colonoscopies, mammograms, CT chest scans for lung cancer, or Pap smears, because these patients are at higher risk for a second malignancy.

Patients may have other comorbidities that we need our internal medicine colleagues to help us with. The last time I treated diabetes, Barack Obama was president, so it's important to work together because I don't have the latest knowledge. Drugs I prescribe may make diabetes worse; a lot of drugs can make hypertension worse. So we need to work together.

We do have a survivorship care plan for patients who are discharged from the oncology clinic. It is very important that the survivorship care plan is passed on to the internal medicine physicians. It is our duty as oncologists to provide this care plan, because the pace of oncology is moving very, very fast and we should not expect our internal medicine colleagues to keep up with their specialty and ours. The survivorship care plan can also be given to the patient, and it will be sent to the primary care doctor's office and will also be in the chart. So there's three different ways to get the plan, and all of these should be completed, in my opinion.

The care plan should include permanent side effects of the patient's treatment and should highlight the importance of certain follow-ups and certain cancer screenings. A care plan is a permanent document that encompasses different phases of survivorship. As a lung cancer doctor, I call primary care doctors, when able to, directly very often because my patients have high needs. I'm very, very fond of phone calls. I keep my cell phone on because communication is care. It is my duty as an oncologist to communicate with my internal medicine colleagues. All medical oncologists, we are internal medicine physicians as well.

A lot of my patients live far away. Recently, I called one of my primary care doctor partners—I call them partners, because we're partners in care for our patients—and we were discussing the best ways to serve our patient over a long distance. We divided tasks, and that was very, very helpful. These tasks included lab work in between chemo, which will be done at the primary care doctor's office. Other lab work like infusions will be done at the oncology clinic, and we were able to create that communication about who's responsible for what.

That's the main obstacle: Who does what? The number-one challenge is the division of the tasks and communication, because despite having many ways of communicating, email, pager, EPIC, text messages, and phone calls, it is still hard to communicate. So clear forms of communication are key and divisions of tasks are key, as well as setting clear expectations for the patient.