Lung Cancer Survivorship

Survivorship

The number of cancer survivors is estimated to continue to grow given advancements in detection and treatment of cancer. Survivorship begins from the time of diagnosis and lasts throughout one's life, and thus is ideally integrated into the cancer care continuum. Survivorship includes not only the patient, but family members/caregivers as well. Survivorship broadly includes the principles and practices of surveillance for recurrence of disease/primary cancers, treatment of long-term and late effects of cancers and its treatments, physical health promotion, and emotional well-being.

While the overall survival rates for lung cancer have improved with the use of screening modalities and a decline in smoking rates, the overall survival rate for lung cancer is estimated to be 19%. However, this varies greatly based upon the time of detection. In those patients diagnosed with localized stage disease, the survival rate is 57%. For those diagnosed with metastatic disease, the 5-year survival rate is 5%. Future rates of survivorship will likely continue to be impacted by the implementation of early detection programs, such as the ones utilizing low-dose computed tomography (CT) for screening.

Cancer survivorship includes multidisciplinary care involving different specialists and practitioners with a patient-centered approach to treatment. An essential component of survivorship care is following clinical practice guidelines for detection of malignancy as well as screening for late effects of treatment. Comprehensive survivorship teams can include a primary care physician, nurse, oncologist, psychologist, rehabilitation team, dietician, and other specialists. Primary care physicians or speciality trained nurses can act as the coordinating providers during survivorship care. These coordinators can then refer survivors to specialized care that is required to address their symptoms such as neuropsychology, cardiology, neurology, endocrinology, and rehabilitation specialists.

Primary care physicians and oncologists may provide preventative care services and screening for cancer recurrence including routine history and physical exams at visits. Physiatrists and other rehabilitation professionals may act on the team to identify physical and cognitive impairments in lung cancer survivors. Palliative care teams can also be utilized in survivorship care to manage persistent pain after disease-directed treatment and taper opioids to mitigate the risk of opiate misuse.

Survivorship visits for lung cancer patients can include the use of survivorship care plans. These care plans can be used to communicate and coordinate care between providers and assist patients in navigating their future care. A summary of previous treatment should include the cancer stage and diagnosis, contact information for previous providers, surgeries, chemotherapies and/or radiation received, and on-going toxicities. Follow-up care plans have information related to clinic visits and continued diagnostic surveillance testing, emotional and financial resources, smoking cessation, and other information promoting a healthy lifestyle and diet.

(See figure: Lung Cancer Survivorship Care Plan and ASCO Cancer Treatment and Survivorship Care Plan).

Quality of Life in Lung Cancer Survivorship

Quality of life in lung cancer survivors has been demonstrated to be worse than in that of the general population. Quality of life in lung cancer survivors can be impacted by physical functional decline, emotional distress, fatigue, pain, cough, and dyspnea. Dyspnea has been repeatedly demonstrated to be an important risk factor for poor quality of life. Mental distress is also an important correlate for a lower quality of life. Identifying, rehabilitating, and improving all of these factors are important for improving survivorship and quality of life in this patient population.

Staging of cancer and treatment types can be important factors impacting quality of life. Surgical resections that are more extensive such as bilobectomy and pneumonectomy may negatively impact quality of life more so than compared to a lobectomy. Furthermore, patients who undergo combined chemotherapy and radiation therapy may be more susceptible to toxicity resulting in increased symptom burden.

There are multiple measurement tools which can be used to evaluate quality of life specifically in the lung cancer population. The European Organization for Research and Treatment of Cancer (EORTC) LC-13 questionnaire provides a list of symptoms related to lung cancer and its treatments. The Functional Assessment of Cancer Therapy questionnaire (FACT-L) is a 41-item survey which covers general health status, in addition to site specific symptoms. Lastly, the Lung Cancer Symptom Scale (LCSS) involves patient and observer evaluation of symptoms.

A survivorship model of care is important to address these quality of life concerns regarding long term surveillance, for recurrence of cancer, symptom management and treatment of other comorbidities. One example of this model involved a nurse practitioner (NP), providing the follow up care for thoracic cancer patients. These survivorship visits included surveillance for recurrence of cancer, assessment and management of effects of treatment, screening for second malignancies and health promotion (diet, exercise, smoking cessation, referrals to support groups and other specialists). This survivorship model of care successfully identified lung cancer recurrences/new lung cancers and provided an assessment and treatment for cancer associated medical and psychological issues which impact quality of life.

Tobacco Cessation

Smoking cessation is an essential aspect of survivorship in lung cancer. This is crucial because individuals who continue to smoke after diagnosis of early stage lung cancer have been shown to have a higher risk of recurrence, a higher risk of second primary tumor, and a higher mortality rate. Clinical practice guidelines generally recommend that all current smokers are advised to quit and for former smokers to remain abstinent.

There are many different strategies and modalities to approach smoking cessation. Patients should be asked about their tobacco use at each visit and be advised about the benefits of quitting and willingness to discuss cessation. A framework which can be used to facilitate these discussions include the “5 As”: ask, advise, assess, assist, and arrange. Counseling on cessation can be performed through phone call quit-lines, group classes, or individualized counseling.

In addition to counseling, pharmacotherapy is another means to assist with smoking cessation. Nicotine replacement therapy can be performed with transdermal patches, lozenges, or gum. Bupropion is a non-nicotine alternative medication to assist in cessation and can also act as an antidepressant. Another alternative is to use varenicline which acts as a partial agonist to nicotinic acetylcholine receptors.

Cancer-Related Pain

Cancer-related pain can be a significant factor impairing the quality of life of lung cancer survivors. Up to 45% of cancer patients will experience inadequate pain control and 40% of cancer survivors will still experience symptoms at 5 years post-treatment. Possible mechanisms for pain include the tumor itself or impingement upon adjacent tissue, obstruction of blood vessels, side effects from radiation and chemotherapeutic agents, and post-thoracotomy pain. Therefore, methods for managing pain symptoms should be incorporated into survivorship.

Lung cancer survivors should be screened for common causes of pain in this population which can include chest wall pain, post-thoracotomy pain syndrome, myofascial pain, chemotherapy-induced peripheral neuropathy, and radiation therapy–related pain. Multimodal approaches can be utilized to manage these pain symptoms. The World Health Organization (WHO) Analgesic Ladder can be utilized as a tool by which pharmacologic management of pain can be prescribed in a stepwise fashion. Rehabilitation therapies can be incorporated into treatment plans for techniques such as myofascial release and stretching exercises. Additional interventional approaches to pain management can include peripheral injections or intercostal nerve blocks, thoracic nerve root/paravertebral procedures, and trigger point injections.