乌鸦传媒

The acknowledgment and advancement of survivorship care has been a boon to patients with cancer from the time of diagnosis through the "balance of life." But patients with advanced cancer have historically gotten short shrift when it comes to survivorship care.

"People living with advanced lung cancer represent a group whose supportive and survivorship care needs remain understudied," said Emily Tonorezos, MD, MPH, of the National Cancer Institute in Bethesda, Maryland, and colleagues, including Maya Kavitha Ramachandran, MD, of Stanford Healthcare in Palo Alto, California.

In their review, they took a look at the "current status of the palliative and survivorship care infrastructure for patients with advanced lung cancer and provide suggestions across the care continuum for this diverse group of patients and families."

Among the highlights of the review:

• Because cancer survivorship is more than surveillance imaging, holistic and individualized approaches need to be considered. A "novel survivorship clinic model provides the opportunity for patients and caregivers to meet one-on-one with specialists in multiple domains (including medical oncology, palliative care, integrative medicine, nutrition, and psychosocial oncology) to develop a personalized approach to education and symptom management."

• While there is currently no gold standard for survivorship care tailored specifically for patients with advanced cancer (of any type), commonly used care models can be of assistance. These are standalone, consultative, embedded in primary care and comanagement models, with most survivorship programs adopting longitudinal or consultative structures.

• Palliative care can run concurrently with survivorship care in the care continuum "to initiate early conversations about symptom control, advanced care planning/end-of-life concerns, or psychiatric or mental health issues." Patients with advanced lung cancer may benefit from both survivorship and palliative care, made up of ongoing anticancer treatment, such as chemotherapy, immunotherapy, and radiotherapy, supportive care, and palliative care.

• Patients may experience higher levels of distress related to stress, anxiety, and living with prognostic uncertainty, which were identified as unmet needs. Education -- for example, regarding prognosis, lifestyle modification, options for support, and treatment advances -- is essential for managing uncertainty and planning for the future.

Tonorezos and colleagues emphasized that survivorship care will need to be tailored even more to older, frail patients; those who carry genomic mutations who will get specialized treatment, such as tyrosine kinase inhibitors, but may have other burdens as a result; and those in underserved populations.

The latter issue was addressed in a study presented at ASCO's 2024 annual meeting by Fangyuan "Chelsea" Chen, MD, of Tsinghua University in Beijing. She and her colleagues assessed the "."

Then, in a at the meeting, Ramachandran and colleagues looked at the feasibility of a primary care-based survivorship clinic for geriatric patients. The team collected patient data (10% of whom had lung cancer) by electronic health record review at an established primary care clinic for cancer survivorship.

Finally, at the 2024 meeting of the British Thoracic Oncology Group, Robert Rintoul, PhD, of the University of Cambridge & Royal Papworth Hospital NHS Foundation Trust in Cambridge, England, gave an overview in a video of the needs of lung cancer survivors in the U.K.

What was the impetus for your respective studies?

Chen et al: SDOHs [social determinants of health] contribute to patients' cancer survivorship outcomes. Our study aimed to understand SDOH profiles in cancer survivors and stratify social risks by analyzing relationships between SDOH profiles and health outcomes using a nationally representative dataset.

We conducted an unsupervised clustering analysis using 2013-2018 National Health Interview Survey [NHIS] data, linked to NHIS mortality files, to examine 12 SDOHs in the general population, including unmarried status, unemployment, having less than a high school education, material/psychological/behavioral financial hardship, transportation/food/housing insecurity, delayed care due to other reasons, and low income (less than federal poverty line), and low neighborhood cohesion.

Ramachandran et al: The largest segment of the growing population of cancer survivors is at least 65 years of age, a population that is likely to have comorbidities and requires co-management between primary care and specialist physicians. The goal of this study was to characterize care for this patient population in a specialized primary care for cancer survivorship clinic that manages survivorship issues and ongoing primary care in one place.

What were some of the main findings?

Chen et al: We identified five distinct groups based on their SDOH profiles, including:

• Group A (few SDOH barriers)

• B (unmarried but no other SDOH barriers)

• C (unemployed but no other SDOH barriers)

• D (unmarried, unemployed, occasionally having other SDOH barriers)

• E (the highest rate of financial hardship/transportation/food/housing insecurity/low neighborhood cohesion/low income)

Notably, group E, compared with all other groups, had the highest rate of racial minorities in both younger (71% vs 5-14%) and older populations (74% vs 1-8%). Older survivors in Group C, Group D, and Group E had significantly lower overall survival rates compared with those in Group A.

Ramachandran et al: Cancer surveillance was discussed with 81% of patients, and 5% of post-treatment patients were diagnosed with recurrent cancer. Secondary cancer screening was performed in 86% of patients, with no secondary cancers diagnosed.

The most common referral sources were medical oncology from the same institution (40%). The average number of visits per year was 2.8, with 61% in person and 29% via video.

Cardiovascular [CV] risk was addressed in 98% of patients; 32% had at least one CV medication started, and 17% were referred to a cardiologist for management. Long-term and late effects were addressed in 84% of patients, including mental health (70%), bone health (65%), cognitive function (21%), cancer-related fatigue (13%), and sexual health (11%). Ten percent had end-of-life issues or goals of care addressed.

What is the main take-home message?

Chen et al: SDOHs form distinct clusters, each with profound effects on cancer survivorship especially among older survivors facing complex social challenges. This necessitates customized health interventions focused on these SDOH profiles, crucial for improving patient outcomes and addressing health disparities.

Ramachandran et al: This study demonstrates the feasibility of a primary care-based cancer survivorship clinic to address the ongoing needs of geriatric cancer survivors. Quality review of these patient encounters can identify gaps in care delivery and inform new models of comprehensive care for the growing geriatric cancer survivor population.

What is considered the ideal follow-up for lung cancer long-term survivors?

Rintoul: We're in a good position with lung cancer, with increasing survival rates. Now, patients who've had oncological treatment, such as chemoradiation, and some patients who are having systemic chemotherapy and immunotherapy, are living for much longer. This is something that has changed dramatically over the last 20 or 30 years. That in effect has brought into focus follow-up; how are we following up patients?

We follow patients up post-treatment, to deal with any complications they have from their treatment -- surgical complications, oncologic complications -- but they're usually dealt with in the first year or so of treatment. Follow-up for lung cancer is generally in most centers in the U.K. around 5 years, and the majority are doctors following patients looking for evidence of recurrent disease.

But actually as we cure more and more patients, and we have an increasing cohort of long-term survivors, we are observing an increasing number of developing second primary lung cancers, and this is something that we haven't really seen before. We need to change the way we follow people up, we need to think again.

Most people are following patients for 5 years, and I would argue that we need to follow people for longer. We need to look for these second, primary lung cancers.

Read the review here and expert commentary about it here.