It is estimated that there are more than two million patients in the UK living with a diagnosis of cancer. This number is increasing due to the changing age profile of the population and as cancer treatments become more effective.
Many of these patients will experience long-term consequences of cancer, both of the disease itself and of treatments. With many patients discharged to primary care for follow-up, GPs need to be alert for possible treatable problems.
The National Cancer Survivorship Initiative was launched in 2008 in response to the Cancer Reform Strategy with the aim of co-ordinating a response to this challenge across all care settings.
Late consequences of treatment
Long-term consequences can arise anything from a few weeks after treatment to many years later.
There is no evidence that the development of late consequences decreases with increasing survival time after treatment.
Physical effects include fatigue, weight gain, lymphoedema, neuropathic pain, heart damage leading to an increased risk of cardiovascular disease, lung damage, bowel and bladder dysfunction and increased risk of osteoporosis.
In addition, there is a risk of cancer survivors developing a second cancer.
Many patients can also suffer psychosocial consequences, including anxiety and depression, memory loss and problems with concentration. This can lead to increased risk of job loss, financial problems, marital breakdown and divorce, and lower educational attainment for children and adolescents with cancer.
A survey by Macmillan Cancer Support in 2008 showed that while 44 per cent of cancer patients were not aware of the possibility of long-term physical side-effects, 78 per cent of them admitted to experiencing at least one of a list of possible side-effects in the preceding 12 months.
The survey also indicated that the majority of patients living with cancer would go to their GP in the first instance for help with their symptoms.
Cancer treatment for children and adolescents, and also for adults, is a risk factor for cardiovascular disease in later life. In particular, radiotherapy to the left side of the chest and some chemotherapy agents, such as anthracyclines, are known to increase the risk of cardio- vascular disease.
As treatment for childhood cancer has become more successful over past decades, we can expect to see rising numbers of patients who are at increased risk of developing ischaemic or valvular heart disease as a result of their treatment.
Platinum-based treatments, used in some breast cancer patients and after bone marrow transplants, increase the risk of the patient developing metabolic syndrome in later life.
Hormonal treatment, including the use of gonadotropin-releasing hormone analogues for prostate cancer and aromatase inhibitors for breast cancer, is associated with an increased risk of bone fractures due to osteoporosis.
NICE has recommended that women with early invasive breast cancer should have a baseline DEXA scan to assess bone mineral density.
Increasingly urologists are adopting the same approach with men with metastatic prostate cancer. Osteoporosis, when identified, should be treated with bisphosphonates.
It has been calculated that there are around 80,000 cancer survivors with a history of pelvic radiotherapy.
About half will have bowel and/or bladder problems and half of these will have severe problems including diarrhoea and incontinence.
These symptoms are stigmatised and patients are reluctant to describe themselves as incontinent, preferring to use words such as leakage and soiling instead. It has been shown that patients with faecal incontinence will not seek medical advice as they are either too embarrassed, or believe that medical care will not help.
Other patients are able to deny their faecal incontinence because they take drastic measures, such as not leaving their home or not eating for some hours before going out.
The role of GPs?
GPs need to be aware of the possibility of late effects for patients with a history of cancer. When a patient presents with new symptoms consider if they are related to the past cancer, its treatment or possibly the development of a new cancer.
The patient records should be clearly coded with details of past oncological treatments and also coded as 'At increased risk of ...' if appropriate.
Cancer specialists need to provide clear information to both patients and GPs about possible long-term consequences and GPs need to ensure that information is appropriately recorded and coded on the patient's GP records.
Patients may change GP so it is essential that facets of the medical history are not lost with each new summarising of records.
Practices can create a register of those who have had oncological treatment including radioand chemotherapies so that those patients can be highlighted on their computer system and alerts set.
Proactively ask patients about possible treatment-related problems and potential psychosocial effects as part of any regular review and consider offering patient information on long-term effects.
There is excellent patient information on radiotherapy and late effects from Macmillan Cancer Support.
Remember that second cancers are common in patients who have already had one cancer. It is vital to give suitable lifestyle advice to all cancer patients to try to reduce that risk.
Actively identify and manage other risk factors for those patients at increased risk of developing cardiovascular disease or osteoporosis.
Patients will be increasingly discharged to primary care for follow-up; ensure patients at increased risk of long-term consequences of cancer or its treatment are given appropriate care and support to lead as healthy and active a life as possible, for as long as possible.
- Dr Burton is a Macmillan GP adviser for London and the south-east of England.
- With thanks to Dr Jervoise Andreyev, Professor Alastair J Munro and Dr Hong Tseung for their contributions.