The importance of the challenge facing the growing number of long-term cancer survivors has been highlighted in previous chapters on cancer survivorship and survivorship and rehabilitation in the EU. In 2010 the National Cancer Survivorship Initiative (NCSI) confirmed that a significant minority of cancer survivors had unmet needs after treatment, and identified three questions.1
In this chapter we review the clinical approaches available for managing these consequences and highlight some clinically challenging examples. At least one in four cancer survivors (approximately 625,000 people in the UK) have one or more physical or psychological difficulties as a result of their cancer or treatment which have a long-term effect on their lives, including 350,000 with severe fatigue, 200,000 with moderate to severe pain, 150,000 with urinary problems and 90,000 with faecal urgency, incontinence, diarrhoea, etc.2
People living with the consequences of cancer treatment
People with (or at risk of) the consequences of cancer treatment can be placed into three broad groups which differ in terms of the severity and prevalence of the consequences with which they live. Categorization into groups helps define optimal approaches to the identification and management of people's care needs.
Group 1: Severe, chronic consequences requiring specialist support
These consequences stand out as having the highest impact and often the highest profile among the consequences of cancer treatment.
They affect a small number of people (1-5% of those treated).
They have a severe impact on QOL over many years.
They often affect multiple organs/body areas, and therefore require input from multiple clinical specialities.
Example: Radiation-induced brachial plexopathy
A radiotherapy technique to treat breast cancer, most commonly used in the 1970s, led to complex regional pain, loss of arm movement, and tissue damage. Patients were identified through a national call, and published guidance was prioritized. Multidisciplinary assessment was found to be essential to diagnose this condition and to determine the most appropriate level of care, including specialist rehabilitation to reduce distress and delay disability.3 This led to specialized commissioning of the Breast Radiotherapy Injury Rehabilitation Service.4
Group 2: Moderate or mild long-term symptoms that can be self-managed and/or treated by local services/primary care
These consequences affect a greater proportion of people (5-25% of those treated, depending on treatment type and other factors).
They are unlikely to be identified without patient-reported outcome measures (PROMs), as they may not be reported as a 'severe toxicity', but they do have a negative impact on QOL.
Example: Bowel urgency as a consequence of pelvic cancer treatment
Bowel urgency is a common but debilitating symptom following pelvic radiotherapy, ...