Cancer survivors are at risk of not only cancer recurrence but also a second primary cancer. Their risk of a second cancer is typically higher than the risk of a first cancer in the general population, but an individual survivor’s risk varies by the type of initial cancer and other factors. To help cancer survivors manage this risk, the clinical services at The University of Texas MD Anderson Cancer Center include risk reduction and screening for second primary cancers.
The unprecedented growth in the number of cancer survivors—according to the American Cancer Society, this population grew from 13.7 million to 14.5 million between 2012 and 2014—has created a demand for health care services tailored to these patients’ needs.
“Cancer survivors have unique medical and psychosocial needs,” said Therese Bevers, M.D., a professor in the Department of Clinical Cancer Prevention and the medical director of both the Cancer Prevention Center and the Prevention Outreach Program at MD Anderson, “and these needs have not always been adequately addressed. But that is changing.”
MD Anderson is looking at every possible way to improve survivors’ health and quality of life, and one of those ways, Dr. Bevers said, is reducing their risk of getting another cancer. For this reason, in addition to 11 multidisciplinary, disease-specific adult cancer survivorship clinics and one childhood cancer survivorship clinic, the institution offers risk reduction and cancer screening services to cancer survivors through the Cancer Prevention Center.
Reducing survivors’ risk of a second cancer
At MD Anderson, the comprehensive survivorship care plan for all patients comprises four domains: surveillance for recurrence of the cancer; monitoring and treatment for late effects of the cancer or its treatment; optimization of psychosocial functioning, which focuses on quality of life issues; and prevention, which aims to reduce the risk of second primary cancers and also screen for the early detection of such cancers. It is this last domain that is overseen by Dr. Bevers.
Dr. Bevers and the Cancer Prevention Center staff identify each survivor’s risk factors and make recommendations through a two-pronged approach of risk reduction and screening. Risk reduction looks at strategies for reducing or eliminating risk factors to prevent cancers from developing, while screening focuses on early detection, whether of a precancerous lesion that can be removed before it progresses to cancer or an early-stage cancer that is much more likely to be treated successfully than a late-stage cancer.
While not all survivorship care at MD Anderson is provided through the Cancer Prevention Center, more and more patients benefit from the center’s focus on reducing the risk of a second primary cancer.
Risk factors for a second primary cancer are not much different than those for an initial cancer. Some of these factors cannot be controlled, such as genetics and aging; others are difficult to control, such as environmental exposures; but some can be controlled, such as lifestyle factors and preventable infections. And there are factors unique to cancer patients, generally related to previous cancer treatment, that increase the risk of certain cancers. For example, radiation therapy can increase the risk of skin cancer, and some chemotherapy agents can increase the risk of leukemia.
While little can be done to mitigate the unavoidable risk factors, many strategies can be employed to eliminate avoidable risk factors. Lifestyle factors such as diet, body weight, physical activity, sun and other ultraviolet light exposure, alcohol use, and tobacco use affect the risk of a second primary cancer for cancer survivors. Infections such as human papillomavirus and hepatitis B are cancer risk factors that can be prevented through vaccination.
While current thinking is that about half of all cancers in the general population are preventable through healthy lifestyle choices and vaccinations, Dr. Bevers believes that number may be closer to 70% if all factors are considered. She acknowledges that the percentage of preventable cancers may be a little lower for cancer survivors because of their inherently higher risk and the unavoidable risk factors related to their cancer treatment, but the Cancer Prevention Center’s mission for cancer survivors is built on the principle that a substantial number of second primary cancers can be prevented.
Healthy Living Clinic helps survivors reduce risk
To help cancer survivors improve their overall health and reduce specific lifestyle-related cancer risks, the Cancer Prevention Center launched the Healthy Living Clinic in January 2013. Clinic staff provide one-on-one counseling targeted at reducing lifestyle-related risks through behavioral changes in five areas: nutrition (including weight management), physical activity, tobacco cessation, psychosocial needs, and complementary therapies. The staff help survivors set specific goals and provide regular follow-up, in person or by phone or computer, to help the survivors meet their goals. Patients may be referred to MD Anderson’s successful Tobacco Treatment Program or to a registered dietitian, social work counselor, or health educator if needed.
To help educate patients about reducing lifestyle-related risks, the Healthy Living Clinic works with the Office of Cancer Survivorship, which has produced booklets and videos to help survivors and their families learn about the specifics of recommended lifestyle changes.
“Our biggest opportunity for prevention is education, particularly about healthy lifestyle and its power to reduce cancer risk,” Dr. Bevers said. “As patients transition to cancer survivorship, their focus shifts from disease to health and wellness. At that point, they are extremely motivated to adopt changes that help promote wellness and reduce further cancer risk. They are ready to hear about avoidable risks and how reducing or eliminating those risks can help prevent second cancers. They’re listening, and that’s when we start the education process.”
OncoLog, June 2016, Volume 61, Issue 6
For more information, contact Dr. Therese Bevers at 713-745-8048.
Continuing Care After Cancer
Reducing the risk of a second primary cancer is only one aspect of comprehensive care for cancer survivors, and such care requires a partnership between cancer specialists and community physicians. Patients who complete their cancer treatment at MD Anderson typically transition gradually back to their primary care provider, continuing to receive survivorship care at MD Anderson while receiving other primary and specialty care in their community. “Our goal is to eventually return patients to their community clinicians for all their medical needs,” Dr. Bevers said. “Our survivorship program is about partnering with primary care clinicians in the community. We want them to learn about the special risks and challenges faced by cancer survivors and to join with us in addressing those challenges.”
To help community clinicians learn about comprehensive survivor care, MD Anderson has published its clinical practice algorithms to guide the care of survivors of different types of cancer. Each algorithm is regularly updated and includes guidelines and recommendations for the four domains of care: surveillance for recurrence, monitoring for late effects, psychosocial care, and prevention of second primary cancers.
Clinicians in the community are invited to review the survivorship algorithms at http://bit.ly/1Vses2J. Other resources for patients and clinicians are available through the Office of Cancer Survivorship, which can be reached by email at firstname.lastname@example.org.
The Growing Number of Cancer Survivors
About 65% of patients diagnosed with any type of cancer 5 years ago are still alive, and that percentage is substantially higher for some cancer types, including two of the four most common cancers in the United States. Specifically, the American Cancer Society reported that in 2014 the 5-year relative survival rates were 99% for patients with prostate cancer, 89% for those with breast cancer, and 65% for those with colon cancer. However, the rate for patients with lung cancer remained among the lowest for all cancers at 17%.