Uniformed Services University of the Health Sciences, Bethesda, MD (Dr. Arnold); Naval Branch Health Clinic, Atsugi, Japan (Dr. Saint); USS Abraham Lincoln (CVN-72) (Dr. Ochab) michael.arnold@usuhs.edu
The authors reported no potential conflict of interest relevant to this article.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, or the United States government.
Few guidelines exist to guide FPs in adjusting screening for the cancer survivor. For women who received radiation therapy for a tumor in the chest, for example, the recommendation offered by several groups is to start breast cancer screening 8 to 10 years after treatment or by 30 years of age, and to consider combining magnetic resonance imaging and mammography.25 Recommendations for breast cancer screening do not account for a history of other gynecologic cancers unless genetic markers are present.25 On the other hand, the impact of a history of cancer on the risk of prostate cancer and on screening decisions has not been studied,26 and cervical cancer screening guidelines, which recommend that screening continue after 65 years of age for patients who are immunocompromised, do not address a history of other cancer.27
4. Manage the effects of both the cancer and the treatment
Medical issues faced by cancer survivors are familiar to FPs, but there are some specific recommendations regarding evaluation and treatment that stand in contrast to what would be considered for a healthy, or non-cancer, patient. For example, each chemotherapeutic agent has characteristic adverse effects; TABLE 47liststhe principal adverse effects of common agents and recommendations for testing when these problems develop. Common long-term problems in cancer survivors include fatigue, chronic pain, cognitive dysfunction, psychiatric illness, and cardiovascular disease. Although these symptoms and manifestations are common, the physician must be careful: New or changing symptoms could signal the spread or recurrence of disease. Fear of recurrence can lead patients to exaggerate or minimize symptoms.
Fatigueis the most common symptom seen in cancer survivors during treatment and following remission.28 More than 40% of cancer survivors report significant fatigue.29 Although fatigue is concerning for cancer recurrence, other causes are common in cancer survivors. Both depression and anxiety commonly present with worsened fatigue.30 Sleep disturbances are common, even without a psychiatric diagnosis.31 Effects of treatment, including nausea, anemia, heart failure, and medication adverse effects can cause or worsen fatigue. Pain is associated with fatigue, but to a lesser extent than are depression, anxiety, and nausea.32
Pharmacotherapy of cancer-related fatigue is challenging. Psychostimulants have been most studied. A recent systematic review shows that methylphenidate produces mild or moderate improvement in fatigue, whereas modafanil has minimal effectiveness.33 Antidepressants have not been shown to relieve fatigue.33
A recent meta-analysis showed that nonpharmaceutical treatments for cancer-related fatigue are more effective than pharmacotherapy. In this review, both exercise and pharmacotherapy had a mild-to-moderate effect on fatigue.35 Exercise is best studied in this regard, and has shown the most consistent results.31
