Survivorship Guidelines Preview: Pearls From the NCCN Conference

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MarkOnly_DottedThe National Comprehensive Cancer Network (NCCN) 18th Annual Conference: Advancing the Standard of Care™ began March 13 and ran through March 17 at the Westin Diplomat in Hollywood, FL—and Connexion Healthcare was there.

Here is the Connexion perspective on an important session:

On March 14, the premier of the NCCN Guidelines for Survivorship was hosted by NCCN Guidelines Panel Chair, Crystal S. Denlinger, MD, and Guidelines Panel Member Jennifer A. Ligibel, MD. This presentation highlights the first publication of the recently drafted Guidelines for Survivorship. There are more than 12 million American cancer survivors according to the National Cancer Institute, and recognizing their needs is a major responsibility faced by oncologists and primary care physicians.

Emphasizing the need for survivorship guidelines, Dr Ligibel opened the premier presentation by asking for a show of hands from those with survivorship programs at their facilities. Fewer than 50% responded positively, confirming that such programs represent a significant unmet need. Although guidelines related to cancer survivorship do exist, Dr Ligibel explained how their heterogeneity lacked focus and stressed the need for a single work that synthesized their content into one practical guide for oncologists and general practitioners alike who must deal with cancer patients who have reached the survivorship stage of treatment.

How do we define survivors? The National Cancer Institute defines a cancer survivor as anyone ever diagnosed with cancer who remains alive, and the NCCN Guideline embraces this definition. Of all cancer survivors, just 11% are over the age of 50, one third have been diagnosed within the past 5 years, and more than 1 million were diagnosed 25 or more years ago, according to Dr Ligibel.  She explained that the new guidelines consider survivorship a continuum that includes all cancer survivors for as long as they live. The few existing metrics in this new field indicate that in some areas, such as physical concerns, we’re serving this population fairly well; however, Dr Ligibel explained, other areas such as emotional and practical concerns reveal a treatment gap that remains insufficiently addressed, while some survivors, she continued, receive unnecessary tests and monitoring.

NCCNRGBlogo Dr Ligibel went on to describe the four essential components to the new guidelines: prevention (eg, adherence to medications, lifestyle changes), surveillance (eg, x-rays, MRIs), intervention (eg, readjustment to normal life), and coordination (eg, oncologist/PCP relationship). Eight distinct areas are addressed: anxiety and depression, cognitive function, exercise, fatigue, immunizations and infections, pain, sexual function, and sleep disorders. The new guidelines contain sample assessment tools with two to three questions in each of these eight areas. Dr Ligibel specifically discussed exercise, cognitive function, sexual function, and sleep disorders—areas that the NCCN has never reviewed.

“Moderate exercise,” said Dr Ligibel, “has been demonstrated to reduce the risk of breast cancer recurrence by 50%, and the same has been shown for colorectal and other cancers. Exercise decreases fatigue, increases quality of life,” she continued, “and data show that 33% of cancer survivors are not exercising.” The survivorship guidelines recommend that physicians ascertain their patients’ capacity for exercise by obtaining a focused history and assessing factors that might limit physical activity, such as physical disabilities, environmental factors, pain, fatigue, emotional distress, and comorbidities. General exercise recommendations are 75 (intense) to 150 minutes of moderate exercise weekly plus two to three weekly strength-training sessions for the major muscle groups. Recommended activities are included in the guidelines, and because it is difficult for patients to know exactly when to begin exercising, risk assessment tools and strategies to engage patients are also included.

Cognitive function, or dysfunction, said Dr Ligibel, remains ill defined and is difficult to assess. Patients with brain metastases are at increased risk due to therapy, but a significant percentage of patients with other types of cancer also develop cognitive dysfunction, making it difficult to say who will suffer from this comorbidity. Cognitive dysfunction usually manifests as memory or executive function disorders, but learning and processing speed deficits are also common. Up to one third of patients with cancer acquire cognitive dysfunction even before beginning chemotherapy. Lack of standards and effective interventions remain challenges in the management of this comorbidity, but the guidelines address general principles to increase awareness, and include an assessment tool with practical recommendations.

Dr Denlinger reviewed the survivorship guidelines in immunizations and infection. The guidelines distinguish between safe (inactive, purified, antigen vaccines) and relatively contraindicated immunizations (live attenuated vaccines) for use in cancer survivors.  Based on age and medical condition, she said, cancer survivors should receive the same immunizations as the general population, according to the guidelines.

Reported in up to 90% of patients with cancer, sexual dysfunction is not often discussed between oncologists and patients owing to lack of time as well as lack of answers to what are often difficult questions. Dr. Denlinger stated that the survivorship guidelines contain specific female and male assessment tools, along with checklists to evaluate patients’ satisfaction with their sexual function. She also mentioned a recent article containing a sexual function checklist that can also be used for assessment.

Cancer survivor assessment is recommended at regular intervals, although the specific timing of these intervals remains to be determined. These are inaugural guidelines, Dr Denlinger observed in closing, and while they require further development, they contain new, significant information within the context of cancer survivorship requiring the collaborative attention of oncologists and PCPs working in a continuum. The guidelines were researched and developed by multidisciplinary panels and subcommittees, and are intended to complement the prevention and specific treatment guidelines.

From the Connexion perspective, we wonder if oncologists and primary care physicians are prepared to assume their respective roles in 2015, when regulations mandate the integration of survivorship guidelines within cancer patient care plans. How will it be decided which responsibilities lie with whom, and who is saying what to whom about reimbursement for these additional services?