CHRONIC CARE FOCUS Colon Cancer: Helping Patients Cope When Active Treatment Ends

Although certain cancers remain difficult to treat and are still associated with early mortality, the 5-year survival rate (considered complete remission) among people of all ages treated for colorectal cancer (CRC) now approximates 62%.^1,2 For many patients, CRC and its treatment's aftermath resemble chronic diseases--patients may die with the cancer, rather than from the cancer, or remain cancer-free until death from another cause. The Institute of Medicine now recognizes cancer survivorship as a distinct phase of cancer care and recommends creating a "survivorship care plan" for patients (Box).³

When active cancer treatment ends, many patients develop a new mix of concerns. Discharged from specialty

care, patients must learn to address health concerns--many of which are related to cancer--in primary practice

settings as "routine" health concerns. It is common for patients to feel abandoned by their oncology team during

this time called "reentry."^4-7 Primary care providers, including pharmacists, may feel unprepared to address what

they perceive as oncology matters, creating continuity of care issues.^8,9 Understanding anticipated health and

transition issues can help clinicians provide better care.

When Treatment Ends

Once chemotherapy ends, oncologists generally wait several months before ordering surveillance testing for CRC patients (Table). The delay allows time for recovery from chemotherapy's effects. During this time, hematologic indexes should improve and tissues heal. Thereafter, oncologists may reduce the frequency of follow-up testing. Occasionally, these tests reveal suspicious hepatic or pulmonary lesions, especially the latter if the patient had radiation. Positron emission tomography scanning or biopsy often prove these benign, but the experience is stressful for patients, reminiscent of the emotional turmoil of their first bout with cancer.¹⁰

Late Effects

Late effects (toxicities that are absent or subclinical at the end of therapy but apparent later) and long-term effects (toxicities that start during treatment and continue) are concerns.^3,11 Surgery, radiation, and chemotherapy cause several expected adverse effects. In general, treatment's lingering and delayed effects fade in the months following treatment, but certain adverse effects may regress slowly.

Bowel cramping and intestinal blockage are common; they diminish or resolve for some people, but for others, they become chronic. Platinum-based antineoplastics often cause acute or chronic pain, burning, weakness, or numbness in the hands or feet. Many patients find their eyes drier or more watery after treatment and may need supportive care. If steroids were used, cataracts may develop later. Fatigue, a serious problem of unclear etiology

for many patients, may persist for years after treatment. Blood counts can remain low, or low-normal, for months or years afterward. Resolution of alopecia (a condition often considered minor by clinicians but terribly traumatic to many patients) usually resolves in stages. Initial hair may be a different color, a different texture, thicker, thinner, curlier, or straighter than pretreatment hair, but eventually it returns to normal. Radiotherapy to the pelvis for rectal cancer may cause permanent pubic or perineal alopecia.

Mental Health Issues

When oncology treatment ends, CRC patients report a range of feelings--from relief, to numbness, to paralyzing

fear. Disease recurrence is always possible, even if survival odds are promising; fear of relapse is normal. Patients

who enjoy the best quality of life are often well-educated about their type and stage of CRC, informed about new

treatment developments, focused onthe positive, and careful about diet and exercise.¹²

Some people expect to function exactly as they did before their cancer diagnosis and are disappointed if they cannot. Recovering stamina can be a slow process. Many patients with CRC have a temporary or permanent ostomy, which is rarely welcome.¹³ These changes can lead to anxiety or depression that is frequently responsive to anxiolytics or antidepressants. Support groups can be very helpful.^14,15 If insomnia, nightmares, or fear interferes with activities of daily living, referral to a counselor who specializes in cancer survivorship is warranted.

Months to Years Later

Until about 20 years ago, cancer survivors treated with surgery, chemotherapy, and radiation did not survive long

enough to characterize lingering problems. Multiagent chemotherapy and combined chemotherapy and radiation

have increased survival and revealed a pattern of late effects. Surgery for CRC is tailored to the patient's specific circumstances, and its late effects vary tremendously. Some late effects from chemotherapyare quite predictable. Visit (www.PharmacyTimes.com/ColonCancer) for a Table describing many late effects with which patients may need help.^3,7,16 In addition, among people of childbearing age, fertility may be restored over months or years following treatment, but permanent infertility is a possibility.

Second Cancers

Among CRC survivors, the risk of developing a second cancer is elevated. Environments or genetic aberrations

that triggered the first tumor may cause a second primary cancer (a tumor distinct from a recurrence or metastasis). This risk is especially pronounced for those with hereditary nonpolyposis colon cancer, the Lynch syndromes, and multiple primary malignant neoplasia. CRC survivors also are more likely to develop second primary tumors in other organs than members of the general population.¹⁷

Radiation therapy has been associated with development of second solid tumors, usually in or very near previously irradiated sites, called radiation ports. The incidence of radiation-induced tumors begins to rise about 15 years

after treatment.¹⁷ Certain antineoplastic classes-alkylating agents, anthracyclines, nitrosoureas, steroids, and topoisomerase inhibitors--are also linked to second cancers.

End Note

Pharmacists can expect to see increasing numbers of people with cancer progressing through and remaining in

the health care system. They will need to anticipate patients' concerns, both physical and psychological, and ask

about lingering and late effects. Regular surveillance for recurrent, metastatic, or new cancers is essential.