Lung cancer patients experience considerable physical and psychosocial sequelae of their treatment in addition to preexisting comorbidities, but there are many opportunities to intervene through surveillance, screening, and management delivered as part of a survivorship program, according to James Huang, MD, a thoracic surgeon at Memorial Sloan Kettering Cancer Center (MSKCC) in New York, NY. At the International Association for the Study of Lung Cancer 17th World Conference on Lung Cancer, Dr Huang described the early experience of a novel thoracic survivorship program at his institution, designed to provide comprehensive, long-term care of lung cancer survivors.
MSKCC defines a survivor as an individual who has received a diagnosis of cancer, completed therapy, and remains disease-free. Over 220,000 lung cancer diagnoses are made in the United States every year, but the disease is not uniformly lethal. “We see about 158,000 lung cancer deaths per year, but that still leaves a difference of over 60,000 patients surviving with lung cancer,” noted Dr Huang, and the number of lung cancer survivors is steadily increasing. In 2014, there were an estimated 430,000 lung cancer survivors in the United States, and by 2024 this figure is estimated to increase by over 25% to more than 530,000 survivors.
Why Thoracic Survivorship?
Thoracic malignancies are the leading cause of cancer-related mortality in the United States. They are associated with a high risk of recurrence and second primaries, for which patients require ongoing surveillance. Leading up to the development of the thoracic survivorship program at MSKCC, Dr Huang and his colleagues examined the volume of lung cancer patients at their institution. From January 2001 to January 2004, they saw 929 patients still living after curative resection, and the majority of these patients (72%) returned to MSKCC for follow-up. In the year 2004 alone, they conducted 2600 posttreatment visits.
At the time, a paucity of postthoracotomy data existed, but they observed a significant decrease in patient quality of life following the procedure, with effort dyspnea the most frequent and single most severe complaint. Comorbidity, continued smoking, and ongoing risk of recurrence were also associated with diminished quality of life and functioning. “Physical functioning does seem to improve over time, but lung cancer patients are worse off than other cancer patients,” he said.
The survivorship initiative at MSKCC began in 2006, and thoracic survivorship was established as 1 of 11 survivorship clinics. At the core of the program are the nurse practitioners, who function independently with physician oversight, and the program integrates various facets of care for lung cancer patients. From 2006 to 2016, Dr Huang and his colleagues have seen tremendous growth in their survivorship program, with a 10-fold increase in activity across all survivorship clinics, he reported.
Essential components of survivorship care include the prevention and surveillance of new and recurrent cancers and other late effects and assessment of late psychosocial and medical effects. Interventions aimed at consequences of treatment also play a major role, as well as coordination of care between primary care providers and specialists to ensure that all survivors’ health needs are met.
Clinical Components of the Program
Patients generally enter the MSKCC thoracic survivorship program after 1 year of disease-free status and are referred to the program directly from their attending physician. “The degree of acceptance for follow-up is much higher when physicians and nurses set expectations for patients early on in their treatment, as opposed to telling them without warning, ‘you’re going to go to a different clinic from now on,’” he noted.
A thoracic survivorship visit at MSKCC includes surveillance for recurrence or new primary cancer, a medical history review, a physical exam and posttreatment psychosocial evaluation, assessment and management of treatment-related sequelae and comorbid conditions with appropriate referrals, a cancer treatment summary, and communication with outside providers. A patient self-assessment addresses various symptom clusters and issues regarding whether the patient currently smokes, activity level, degree of pain, dyspnea, etc.
As of 2014, more than 600 elderly patients were enrolled in the thoracic survivorship clinic at MSKCC. Eighty-four percent were stage IA/IB after resection, 78% were former smokers, and 5% admitted they had gone back to smoking despite efforts at cessation. About one-quarter of patients were still reporting moderate to severe pain after treatment; nearly half reported significant fatigue; and a smaller, but still significant, minority (14%) still described at least mild levels of dyspnea, he reported. Anxiety was reported by about one-third of patients, and a smaller proportion reported clinically significant depressive symptoms, enough to trigger referral to other specialists.
Early experience demonstrated this model of care was feasible and well-accepted by patients, and 92% agreed to stay in the program for follow-up. “This certainly provides a much more comprehensive visit than when they were only followed by their treating physicians,” he noted.
According to Dr Huang, there are certain challenges to getting more patients into this sort of paradigm, including travel and logistical constraints that preclude patients from being involved in a survivorship clinic, as well as capacity and limited space. He said opportunities for improvement include prospective evaluation of patient satisfaction, as well as more vigilant documentation of patient-reported outcomes and quality-of-life measures.