It’s (Supposed To Be) A Wonderful Life: A Case Study Demonstrating the Positive Impact of Survivorship Care

Opinions are varied regarding how “survivorship” should be defined by patients and oncology specialists. There are also mixed opinions about when a patient actually becomes a “survivor.” Is it from the moment of diagnosis? Or should a person be considered a survivor at the time of completion of acute treatment (surgery, chemo, radiation)? Some consider a survivor to be one who has achieved the 5-year mark posttreatment. However, how we as clinicians view this milestone of sorts impacts how we apply survivorship. Just as the character George Bailey in the movie It’s a Wonderful Life has the unique opportunity to see how the world would be different if he had never entered it, my goal is to show how the life of a patient can be dramatically different with the application of effective survivorship care. These fictional case studies are created as a teaching tool to depict the outcomes when we choose to apply survivorship care at the end of acute treatment or even later versus applying it from the point of diagnosis.

CASE STUDY: ABSENCE OF SURVIVORSHIP CARE

A 35-year-old woman was diagnosed with stage IIb breast cancer. She wanted surgery done soon and to undergo surgery once rather than having staged reconstruction. She declined neoadjuvant chemotherapy first. Tumor was ER positive and HER2 negative. She underwent a left mastectomy with reconstruction (bilateral deep inferior epigastric perforator [DIEP] flap) and prophylactic mastectomy on the right side, left axillary node dissection, chemotherapy (docetaxel/cyclophosphamide), and radiation, with hormonal therapy for 5 years.

Outcomes:

• She developed range-of-motion complications that warranted extensive rehab medicine therapy. Several years later she continues to have problems with her arm and shoulder
• Her left flap shrunk as a side effect of radiation, resulting in asymmetry and chronic discomfort
•  Due to chemotherapy and hormonal therapy she was unable to conceive after her treatment was completed. This was a major blow to both her and her husband
• The patient had known atherosclerosis and was advised to have coronary artery bypass graft surgery (CABG), but vessels used for the DIEP flap reconstruction impeded this cardiac surgery procedure
• She later develops lymphedema of her left arm and requires daily treatments for this and her fatigue
• Her heart disease and inability to properly repair it surgically resulted in her developing early-stage congestive heart failure. This resulted in her having shortness of breath when climbing steps and chronic fatigue. These medical problems combined with her shoulder pain and lymphedema resulted in her losing her job
• She suffers now from depression
• Marriage is strained. Finances are tight due to copayments for her continued chronic treatments of long-term side effects and her inability to work
• She was diagnosed 4 years later with ovarian cancer and is still undergoing treatment
• She tells others “getting breast cancer is the worst thing that has ever happened to me in my life”

CASE STUDY: SAME PATIENT, SURVIVORSHIP CARE BEGINNING AT TIME OF DIAGNOSIS

Additional information obtained about this patient included:

• She has been married for 2 years, and she and her husband have been trying to conceive a baby. Neither have any children, and both badly want a child of their own. No previous pregnancies, and this is a first marriage for both of them
• She works as a waitress at a seafood restaurant 5 days a week
• History of rotator cuff injury and repair to her left shoulder 2 years ago
• Her mother had breast cancer at age 45 and died of it at age 48. She thinks her maternal grandmother might also have had breast cancer, but it wasn’t talked about back then. Her grandmother died at age 59
• Family history of cardiac disease. Father had a heart attack at age 52 and died of a stroke at age 56. She has an elevated cholesterol and has been taking a statin for 1 year

BEFORE TREATMENT BEGAN, THE FOLLOWING STEPS WERE TAKEN:

• Referred for genetics consultation and subsequent testing. Results were positive for BRCA1. The patient decides to do bilateral mastectomies as a result. She doesn’t want to do bilateral oophorectomies yet but was referred for a discussion about this with gynoncology
• Referred for a rehab medicine consultation to get instructions regarding range-ofmotion exercises, lymphedema prevention, and ways to prevent reinjuring her shoulder while recovering from her upcoming surgery. The decision was to put in tissue expanders as space holders for now rather than doing immediate DIEP flap reconstruction since she will need radiation as part of her treatment. She will be followed by rehab medicine post-op as well
• Referred for a consultation with medical oncology, and though advised to do chemo first to shrink the tumor along with her lymph nodes, she opted to undergo surgery first. The impact of chemo on her reproductive system was discussed at length. Tamoxifen was also discussed, with a plan for her to take hormonal therapy for 2 years, discontinue for childbearing, and then resume postpartum
• Referred to fertility preservation consultation to discuss how to preserve her desire to still have a biological child. Eggs were harvested since chemo and hormonal therapy would likely cause chemical menopause
• Referred for consultation with plastic surgery regarding the value of staged reconstruction. Patient preferred undergoing surgery once, but when she learned that flaps shrink in response to radiation therapy, she was content to have tissue expanders inserted as space holders for final flap reconstruction later. In recognition of the cardiac history in her family and her own elevated cholesterol levels that warrant treatment, the vessels used for reanastomosing her perforators within the chest area were carefully selected, avoiding those that may be needed for cardiac surgery in the future

Outcomes:

• Patient maintained her range of motion and arm strength post-op
• She did not develop lymphedema by being meticulous regarding adhering to the precautions given her by the rehab medicine staff
• Fertility preservation was successfully performed. After completing 2 years of tamoxifen therapy, she became pregnant through in vitro fertilization and gave birth to a healthy baby boy
• She underwent bilateral salpingo-oophorectomies 6 months postpartum to prevent ovarian cancer. She was placed on an aromatase inhibitor after this rather than resuming tamoxifen
• She did develop heart disease and underwent a successful CABG procedure 6 years posttreatment
• She has experienced few problems with fatigue and has remained active
• Her reconstruction was done as a staged procedure; after her chemo and radiation, she underwent bilateral DIEP flap reconstruction, at which time the temporary tissue expanders were switched out. The reconstruction looked great, without the radiation affecting its cosmetic appearance. She had no chronic pain issues from these procedures
• She continues to work as a waitress at a busy seafood restaurant and now works part-time after the birth of her son so that she can spend more time taking care of him
• She also devotes 2 hours a week to being a survivor volunteer for the breast center where she received her treatment. She provides support to newly diagnosed breast cancer patients
• When asked about her experience, she tells new patients, “I was scared at first when I heard the diagnosis. How was this going to impact my life? Can I still have a child? What am I going to look like? But the team taking care of me here showed me that they just weren’t going to treat the disease; they were going to get to know me as a person and not as someone with stage IIb breast cancer. And in doing so, they helped me stay on track with my life goals. This is truly a wonderful life!”

The measurable difference in the quality of life for this woman when survivorship care is initiated from the onset of the diagnosis is inspiring. By being proactive in the case of this patient, her life goals could be maintained, her physical and emotional quality of life could be preserved, and perhaps even enriched. My recommendation: Start survivorship care simultaneous to confirming the cancer diagnoses of your patients so that they too can say, “it’s a wonderful life.”