With the evolution of cancer treatment today, we see advanced cancer patients living longer. Surgery, radiation and systemic therapy; better living conditions as well as the development of new drugs that come in the form of targeted therapies, immunotherapy and cancer vaccines, contribute to this.
While surgeons do their best to remove all lethal cells during operation, there’s always a possibility of cancer cells being left behind, even with chemotherapy and radiation therapy. With post-cancer care, you will have regular follow ups with your healthcare provider to look for changes in your health due to your cancer treatment and any problems that may arise, such as a cancer relapse.
Fear of Cancer Recurrence, or FCR, is a clinical condition that is defined as ‘the fear, worry, or concern about cancer returning or progressing’, and can evolve into depression, anxiety, and post-traumatic stress symptoms if left unaddressed in cancer survivors. 43.6% of cancer survivors in Singapore have been found to be diagnosed with this psychological condition.
However, with a good understanding of what to expect during your post-cancer treatment, doctors and patients can work together to put those fears to rest. We speak to Medical Oncologist Dr. John Chia and Radiation Oncologist Dr. David Tan about life after cancer treatment.
Cancer survivorship focuses on the health and well-being of a cancer patient from the time of diagnosis until the end of life. The exact course of survivorship is a personalised journey that is different for every individual, with cancer progression impacting the type of follow-up treatments required.
“There’s no one-size-fits-all,” says Dr. Chia. “We follow guidelines but we can’t be too formulaic. It must be individualised.”
For example, Stage 3 cancers carry a real risk of mortality and require more stringent follow-ups and screenings for remnant cells once treatment is over. Stage 1 survivors, on the other hand, are far less likely to have a relapse and will instead be assessed for other health markers such as their heart and bone conditions. This is critical for their long-term well-being, as the chemotherapy and subsequent five years of non-HER2 hormone treatment prescribed for Stage 1 breast cancer can lead to osteoporosis if unmonitored.
According to Dr. Chia, "Chemotherapy and hormonal treatment can cause accelerated bone loss, so vitamin d levels, and osteoporosis need to be identified and corrective measures instituted early."
In addition to the aforementioned side effects, Dr. Tan added that patients may also experience long-term side effects specific to where they received their cancer treatment. In the case of patients with gynecological cancers, the main organs at risk of long-term side effects are the bowel and bladder.
“Some patients experience a change in bowel or urinary habits post-radiotherapy. I usually describe it to patients as a "new normal" that they will get used to with time,” Dr. Tan said. “Generally, these changes in habits are mild, such as passing urine or motion once or twice more per day, compared to prior to their cancer diagnosis.”
Being Asian, some patients may be embarrassed to share them or ask questions relating to these effects. “I usually make it a point to ask about these symptoms regularly. It is actually quite important to pick these issues up as treatments are available.” Dr. Tan added.
Apart from assessing your physical health, doctors work through emotional and mental health challenges that you may experience post-recovery, such as loneliness due to a lack of individuals who can relate to your experience, or frustration with persisting side effects from chemotherapy toxicity.
Late toxicity, in particular, can cause moderate to severe breast or chest wall pain combined with at least one other symptom including impaired arm movement, firmness of the breast, or lymph fluid build-up in the breast, arm, or hand. These experiences may lead to depression, anxiety, insomnia, and even thinking and memory problems. It’s therefore important for cancer survivors to consult their doctors at regular intervals, and continue with cancer screening for other cancers, so as to assess both their emotional and physical conditions.
As Dr. Tan puts it, “As patients survive longer from better treatments and supportive care in the 21st century, more attention needs to be placed on this aspect of a patient's follow-up.”
He shared about patients who would continue to call him years after their treatments are completed. “Every now and then, I still receive worried calls or messages from patients who are two to three years, or even more than five years post-treatment, some of whom may be in tears from the fear of recurrence.”
Dr. Chia added that survivorship can be a lifetime journey for some, especially in cases with cancers that tend to relapse late, such as hormone-positive breast cancer. Whereas for other cancers, their post-cancer care might end after just five years.
“With Granulosa cell tumor (a type of ovary tumor), relapses tend to happen more frequently after 10 years rather than before the 10-year mark. It is only after 10 years have passed that we see cancer cells start coming back,” Dr. Chia stated.
Young cancer survivors, in particular, require specific care because they are more susceptible to health complications further down the road. For example, young lymphoma cancer patients receive a regimen that consists of drugs that are linked with accelerated atherosclerosis.
This means that lymphoma survivors experience plaque build-up in their arteries faster than their peers, leading to early-onset heart disease in their 50s instead of the more typical 70s. It’s therefore advisable for lymphoma survivors to receive early cholesterol intervention in their 30s and 40s while conditions are still manageable.
“You don't want to wait until they are in their 50s, then you've got the blood vessels of a 70-year-old person and not much you can do at that time,” Dr. Chia adds. “So for these people, you will want to be a bit more aggressive with preventing such a thing from happening. All this comes under survivorship.”
Declaring a patient to be 100% cancer free can be tricky when there are instances of recurrence years after treatment has concluded. In fact, the likelihood of recurrence may even increase with time. A family history of cancer also plays a significant role in a patient’s risk profile. It’s estimated that 1 in 8 cancer patients are genetically predisposed to cancer. Such patients may develop a secondary cancer different from their original diagnosis, long after their initial cancer has been treated.
Most cancers abide by recurrence patterns that doctors plan around accordingly. As a rule of thumb, patients who successfully tide through a five-year period relapse-free can be discharged. However, this rule only applies to certain types of cancers that fall within this five-year recurrence pattern, such as Stage 1 and 2 colorectal cancer.
“Some cancers have a dormancy that goes up to 20 years, these would include hormone-positive breast cancers, which we follow up for 10 years or more if it was higher stage, i.e. Stage 2 or 3 when detected”, Dr. Chia explained.
Although the risk of recurrence for most cancers after five years is very low, it does not drop to zero, which is why doctors like Dr. Tan choose to follow up with their patients for life, even offering annual or bi-annual follow ups for his patients once they have passed the five-year mark.
“Most of my patients prefer to maintain the link and see me every now and then in the long term,” he added.
Cancer survivorship has become a critical part of oncological care in the last decade. This is due in large part to the more effective cancer treatments that have improved cure rates or kept patients alive for a longer period of time.
“Technology has played an important role in this story; particularly in radiotherapy treatments,” Dr. Tan said, “Advanced technologies have allowed us to treat patients with increased precision, allowing higher doses to be delivered to the tumor, while surrounding organs receive lower doses. This means that more effective, yet safer treatments can be delivered all at once.”
Training and expertise for radiation oncologists has also improved survivorship care for patients, with subspecialized training that enables them to provide more personalised cancer treatments where a focused approach to site-specific long term side effects and quality of life is given.
The role of an oncologist has undergone a significant transformation, extending far beyond the confines of diagnosis and treatment to encompass long-term survivorship care. This not only enhances the quality of life for cancer survivors but also embodies a proactive stance in preventive care, emphasizing the importance of lifestyle factors and regular screenings in sustaining long-term health and detecting relapses early.
Their evolving role in survivorship marks a paradigm shift towards a more compassionate, comprehensive care model that champions the survivor’s journey well after the initial battle is won.
