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Over 10 million Americans are cancer survivors. The vast majority of these people will bear some mark of their cancer and/or its treatment, and a large proportion will experience long-term consequences that include medical problems, psychosocial dysfunction, economic hardship, sexual dysfunction, and discrimination in employment and insurance. Many of these problems are directly related to cancer treatment. As patients with more types of malignancies survive longer, the biologic toll that very imperfect therapies take in terms of morbidity and mortality rates is being recognized increasingly. These consequences of therapy confront the patients and the cancer specialists and general internists who manage them every day. Although long-term survivors of childhood leukemias, Hodgkin's lymphoma, and testicular cancer have increased knowledge about the consequences of cancer treatment, researchers and physicians keep learning more as patients survive longer with newer therapies. The pace of the development of therapies that mitigate treatment-related consequences has been slow, partly due to an understandable aversion to altering regimens that work and partly due to a lack of new, effective, less toxic therapeutic agents with less "collateral damage" to replace known agents with known toxicities. The types of damage from cancer treatment vary. Often, a final common pathway is irreparable damage to DNA. Surgery can create dysfunction, including blind gut loops that lead to absorption problems and loss of function of removed body parts. Radiation may damage end-organ function, for example, loss of potency in prostate cancer patients, pulmonary fibrosis, neurocognitive impairment, acceleration of atherosclerosis, and second cancers. Cancer chemotherapy may act as a carcinogen and has a kaleidoscope of other toxicities, as discussed in this chapter. Table 55-1 lists the long-term effects of treatment.
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The first goal of therapy is to eradicate or control the malignancy. Late treatment consequences are, indeed, testimony to the increasing success of such treatment. Their occurrence sharply underlines the necessity to develop more effective therapies ...