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Research Articles for Survivors

 

The Epidemic of Vitamin D Deficiency

Deborah Goldstein, Journal of Pediatric Nursing, Volume 24, Issue 4, August 2009, Pages 345-346.

Vitamin D deficiency is of epidemic proportions and is being identified across the lifespan and worldwide1.There are reports of vitamin D deficiency in 36% of healthy young adults, 80% of healthy White infants, and 52% of adolescent African American and Hispanic children2-3. The emergence of vitamin D deficiency can be attributed to multiple factors. The modern-day practice of avoiding the sun because of fear of skin cancer and the use of sun block contribute to the rise of vitamin D deficiency1. In many countries where sunshine is ample, cultural practices requiring women to be covered with clothing contribute to lack of vitamin D1-3. A biologic factor that decreases bioavailability is body fat content, since vitamin D is stored in body fat and unavailable for use. Studies show that body mass index and body fat content have an inverse relation to serum levels of 25 hydroxyvitamin D2-3. The concurrent epidemic of obesity adds to the epidemic proportions of vitamin D deficiency. Another factor contributing to the increase in prevalence of vitamin D deficiency is the lack of knowledge that human breast milk is deficient in vitamin D1. Breast milk is touted as providing all necessary nutrients, and often, mothers are not counseled about their infants' need for sunshine and/or vitamin D supplementation. A recent study showed that at 280 days of age, 10% of breast-fed infants were vitamin D-deficient (25 hydroxyvitamin D <11 ng/ml). Deficiency was significantly more prevalent among dark-skinned infants and during winter and occurred exclusively in unsupplemented infants. During winter, 78% of unsupplemented infants were vitamin D-deficient4. Human breast milk has insufficient vitamin D at approximately 20 IU/L, and many mothers themselves are vitamin D-deficient, impacting fetal growth and development as well as neonatal health1.

References
M.F. Holick, Vitamin D deficiency, New England Journal of Medicine 357 (2007), pp. 266-281.
M.F. Holick, High prevalence of vitamin D inadequacy and implications for health, Mayo Clinic Proceedings 81 (2006), pp. 353-373.
M.F. Holick, Resurrection of vitamin D deficiency and rickets, Journal of Clinical Investigations 116 (2006), pp. 2062-2072.
Ziegler et al., 2006 E.E. Ziegler, B.W. Hollis, S.E. Nelson and J.M. Jeter, Vitamin D deficiency in breastfed infants in Iowa, Pediatrics 118 (2006), pp. 603-610.

Cancer Survivorship: A challenge for primary care physicians

Original Publication: Grunfeld, E. Cancer survivorship: a challenge for primary care physicians. Br J Gen Pract. 2005 October 1; 55(519): 741-742.

An important aspect of the medical management of cancer survivors is cancer-specific follow-up care. Follow-up care consists of periodic routine visits and tests towards the broad goals of detecting recurrence, monitoring late effects of treatment, screening for related new primary cancers and providing psychosocial support. The frequency of visits and the types of tests vary according to the type of cancer. The growing research literature on cancer follow-up care has challenged some of the basic tenets on the value of routine visits and tests for detecting recurrence, as exemplified by current guidelines on breast1 and colorectal cancer,2 which recommend very few routine tests (for example, only mammograms are recommended for breast cancer) and focus on history taking and physical examination. Also challenged is the long-held tradition of providing routine follow-up care in cancer specialist clinics. It has now been shown in two randomized controlled trials - one conducted in the UK and one in Canada - that primary care-based follow-up of breast cancer patients is a safe alternative to specialist follow-up as measured by a range of outcomes, such as delay in diagnosing recurrence, the rate of recurrence-related serious clinical events, health-related quality of life and patient satisfaction.3-5 While these two trials studied breast cancer patients the findings can be arguably viewed as proof of principle for the other most prevalent cancers. Previous research has suggested that family physicians wish to be more involved in the ongoing care of their patients with cancer.6 These two trials have shown that not only are general practitioners willing to assume primary responsibly for follow-up care, but that they can do so with outcomes similar to specialist care.

For survivors of childhood cancers, some have recommended follow-up for life in specialist clinics. Whether this is sensible or feasible is questionable both from the perspective of resource implications and from the perspective of a child growing to adulthood with the associated changes in healthcare needs and location of care. Moreover, pediatric oncology clinics do not have the skills to manage the range and changing healthcare needs of survivors of childhood cancer throughout their lifespan: it is general practitioners who are experts in this form of care. Fragmenting care is not in the best interests of the patient. When discharged, almost all patients are discharged to the care of their family physician,7 and survivors of childhood cancer ranked primary care physicians as the most practical source of long-term medical care.8

Comprehensiveness of care is one of the important potential benefits for cancer survivors of primary care-based follow-up. Most cancer survivors require not just surveillance for the index cancer, but general medical and preventive care. Two studies that examined this question found that patients followed solely by a primary care physician were more likely to receive general medical and preventive care, but less likely to receive cancer specific surveillance such as colonoscopy and mammography.9,10 This finding may be due to ambiguity as to which healthcare practitioner is primarily responsible for aspects of the patient's care, and can potentially be addressed by a clear allocation of responsibility for follow-up to the general practitioner. For the patient, both forms of care are important and neither should be neglected. It can be argued, however, that for long-term survivors of breast, colorectal and prostate cancer the greater health threat lies with other  conditions than with the index cancer.

The possibility of devolution of long-term follow-up care to the primary care setting poses important challenges for general practitioners and cancer specialists alike. These challenges are akin to the dissemination and uptake of new knowledge that faces us in all areas of medicine.11 In the two breast cancer follow-up trials3,4 primary care physicians provided follow-up care with the aid of a simple guideline. While guidelines are an important tool12 they are not always sufficient.11 Many studies have shown that adherence to guidelines by general practitioners can be suboptimal. Mechanisms to improve adherence to guidelines is a hotly researched area of medicine.11 This research points to the multiple factors that influence adherence to guidelines such as the credibility of the guideline producer, potential barriers and supports within the practice environment and - above all - factors unique to the specific patient. Primary care physicians will vary their adherence to a guideline recommendation according to factors unique to the specific patient.12 This points to the importance of engaging cancer survivors as active participants in their long-term care.

General practitioners have stated that they wish to be more involved in the care of their patients with cancer. With the growing prevalence of cancer survivors in the population, the opportunity - along with the challenge - is upon us now.

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References:

1. Smith, TJ; Davidson, NE; Schapira, DV, et al. American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. J Clin Oncol. 1999;17:1080-1082.

2. Benson, AB; Desch, CE; Flynn, PJ, et al. 2000 Update of American Society of Clinical Oncology Colorectal Cancer Surveillance Guidelines. J Clin Oncol. 2000;18(20):3586-3588.

3. Grunfeld, E; Levine, MN; Julian, JA, et al. A randomized trial of long term follow-up for early stage breast cancer: a comparison of family physician versus specialist care. J Clin Oncol. 2005 in press.

4. Grunfeld, E; Mant, D; Yudkin, P, et al. Routine follow up of breast cancer in primary care: a randomised trial. BMJ. 1996;313:665-669.

5. Grunfeld, E; Fitzpatrick, R; Mant, D, et al. Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist care: results from a randomised controlled trial. Br J Gen Pract. 1999;49:705-710.

6. Grunfeld, E; Mant, D; Vessey, MP; Fitzpatrick, R. Specialist and general practice views on routine follow-up of breast cancer patients in general practice. Fam Pract. 1995;12:60-65.

7. Taylor, A; Hawkins, M; Griffiths, A, et al. Long-term follow-up of survivors of childhood cancer in the UK. Pediatric Blood Cancer. 2004;42:161-168.

8. Zebrack, B; Eshelman, DA; Hudson, MM, et al. Health care for childhood cancer survivors: insights and perspectives from a Delphi panel of young adult survivors of childhood cancer. Cancer. 2004;100:843-850.

9. Earle, CC; Neville, BA. Under use of necessary care among cancer survivors. Cancer. 2004;101:1712-1719.

10. Earle, CC; Burstein, HJ; Winer, EP; Weeks, JC. Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol. 2003;21:1447-1451.

11. Grimshaw, JM; Thomas, RE; MacLennan, G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):1-72.

12. Zitzelsberger, L; Grunfeld, E; Graham, ID. Family physicians' perspectives on practice guidelines related to cancer control. BMC Fam Pract. 2004;5:25.


 

Breast Cancer Survivors: Take care to preserve bone strength

 While many women worry about keeping their bones strong and stable as they age, survivors of breast cancer may need to take special care to preserve bone health and strength, say health experts.

New research from the University of Arizona, Tucson has used data from the Women's Health Initiative Observational Study (WHI-OS) to draw conclusions about the effects of living through breast cancer on bone density.

The research, published in Archives of Internal Medicine, found that postmenopausal breast-cancer survivors may have a higher risk of fractures in bones excluding the hip bone than their counterparts who have not undergone breast-cancer treatments.

The study was conducted by Zhao Chen, Ph.D., M.P.H. and colleagues at the University of Arizona. The team compared bone fracture rates in a group of 5,298 women who had breast cancer with a group of 80,848 women who had no history of breast cancer over a five-year period. Women gave information on their fracture histories in questionnaire form, and the fractures were placed into four categories: hip, forearm/wrist, spine or back, and other fractures.

Chen and colleagues found that aside from hip fractures, which seemed to occur with the same frequency in both groups, "fracture rates were higher in the breast-cancer survivors than in the reference group. Overall, breast-cancer survivors may sustain 68.6 excess fractures per 10,000 person-years compared with other women in the same age group."

A person-year is defined as the number of the persons multiplied by the number of years of observation.

The researchers adjusted the figures to account for other risk factors, including medication use, hormone replacement therapy, prior history of fractures and lifestyle, but found that the increased risk held true in spite of these adjustments, suggesting a likely correlation between breast-cancer survival and bone fractures.

Previous studies involving smaller populations have found that postmenopausal breast cancer survivors suffer from accelerated bone loss after chemotherapy for breast cancer and have low bone density, but findings on fracture risk have been inconsistent.

With further research, noted the authors, "the excess number of fractures may be as high as 13,000 per year for the two million postmenopausal breast cancer survivors in the United States." They concluded "more research is needed to understand the fracture risk in this special population and to develop strategies to reduce the number of fractures among breast-cancer survivors."

References:
Chen Z, Maricic M, Bassford TL et al. Fracture risk among breast-cancer survivors: results from the Women's Health Initiative Observational Study. Arch Intern Med. 2005 Mar 14;165(5):552-8. 

 

 

Preventing second cancers in cancer survivors


An excerpt from: Wilkins KL, Woodgate RL. (2008). Oncol Nurs Forum. 35(2):E12-22.


One of the most incredible success stories of modern medicine is that a cancer diagnosis is no longer a death sentence. For many, cancer is a survivable illness. Whereas few people survived cancer 40 years ago, 59 to 65 percent of adults and 70 to 92 percent of children will survive beyond five years after a cancer diagnosis today (1,2). An estimated 3.3 percent of Americans are cancer survivors (2).

Despite these encouraging statistics, progress in survival has come at a cost. Being cancer-free does not mean being free from the effects of the illness and its treatment. In fact, many survivors encounter long-term changes in their health status that are absent immediately after cancer treatment but manifest later when they are considered "cured" from cancer (3,4). Recent research suggests that approximately 62 percent of cancer survivors have had at least one chronic health problem, 28 percent a severe condition, and 24 percent have three or more chronic health problems (5).

One of the most devastating late effects cancer survivors face is the development of a new cancer arising as a result of the mutagenic effects of treatment, genetic predisposition, or aging. Second cancers are concerning because they predispose survivors to morbidity and early mortality through their effect on general health, quality of life, and long-term survival (6).

At least 750,000 Americans (almost 8 percent) have been diagnosed with more than one form of cancer, and it is expected that at least one in nine people will develop two cancers in his or her lifetime (7).

Survivors of childhood cancer are 3 to 11 times more likely to develop cancer compared to the general population (8,9). Estimates suggest that, following cancer in adulthood, survivors have a two-fold risk of developing cancer (10,11). Common second cancers include leukemia and solid tumors, particularly cancers of the breast and thyroid. An emerging risk for childhood cancer survivors is the development of cancers of adulthood, including cancers of the genitourinary system, head and neck area, and gastrointestinal tract (12). Most concerning is that second cancers may appear at any time during cancer survivorship and develop at a much younger age than in the general population (4,13).

The implication of this increased risk for second cancers is the need for comprehensive cancer care that extends from the cancer diagnosis until death (14). Once long-term survival has been achieved, vigilant care must continue in the form of secondary prevention interventions (6). In the general population, secondary prevention interventions, including life-long surveillance, cancer screening, and health education, are recommended for the early detection of cancers and timely introduction of treatments to prevent or control cancers before signs and symptoms are apparent (15). For cancer survivors, this proactive approach to cancer control translates into maintenance of cancer-free survival and prevention of cancer-related morbidity (14).

References:

1. Davies, S.M. (2007). Subsequent malignant neoplasms in survivors of childhood cancer: Childhood Cancer Survivor Study (CCS) studies. Pediatric Blood and Cancer, 48(7), 727-730.

2. Ries, L.A.G., Harkins, D., Krapcho, M., Mariotto, A., Miller, B.A., Feuer, E.J., et al. (2006). SEER cancer statistics review, 1975-2003. Bethesda, MD: National Cancer Institute.

3. Oeffinger, K.C., & Hudson, M.M. (2004). Long-term complications following childhood and adolescent cancer: Foundations for providing risk-based health care for survivors. CA: A Cancer Journal for Clinicians, 54(4), 208-236.

4. Tichelli, A., & Socie, G. (2005). Considerations for adult cancer survivors. Hematology, 1, 516-522.

5. Oeffinger, K.C., Mertens, A.C., Sklar, C.A., Kawashima, T., Hudson, M.M., Meadows, A.T., et al. (2006). Chronic health conditions in adult survivors of childhood cancer. New England Journal of Medicine, 355(15), 1572-1582.

6. Hudson, M.M. (2005). A model for care across the cancer continuum. Cancer, 104(Suppl.), 2638-2642.

7. Mariotto, A.B., Rowland, J.H., Ries, L.A., Scoppa, S., & Feuer, E.J. (2007). Multiple cancer prevalence: A growing challenge in long-term survivorship. Cancer Epidemiology, Biomarkers, and Prevention, 16(3), 566-571.

8. Cardous-Ubbink, M.C., Heinen, R.C., Bakker, P.J., van den Berg, H., Oldenburger, F., Caron, H.N., et al. (2007). Risk of second malignancies in long-term survivors of childhood cancer. European Journal of Cancer, 43(2,) 351-362.

9. Inskip, P.D., & Curtis, R.E. (2007). New malignancies following childhood cancer in the United States, 1973-2002. International Journal of Cancer, 121(10), 2233-2240.

10. Mahon, S.M. (2005). Tertiary prevention: Implications for improving the quality of life of long-term survivors of cancer. Seminars in Oncology Nursing, 21(4), 260-270.

11. Somerville, H.M. (2003). Second malignant neoplasms following treatment for primary cancer. Australian Family Physician, 32(1-2), 25-31.

12. Bassal, M., Mertens, A.C., Taylor, L., Neglia, J.P., Greffe, B.S., Hammond, S., et al. (2006). Risk of selected subsequent carcinomas in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Journal of Clinical Oncology, 24(3), 476-483.

13. Bhatia, S., Blatt, J., & Meadows, A.T. (2006). Late effects of childhood cancer and its treatment. In P.A. Pizzo & D.G. Poplack (Eds.), Principles and practice of pediatric oncology (5th ed.). Philadelphia: Lippincott Williams and Wilkins.

14. Pollack, L.A., Greer, G.E., Rowland, J.H., Miller, A., Doneski, D., Coughlin, S.S., et al. (2005). Cancer survivorship: A new challenge in comprehensive cancer control. Cancer Causes Control, 16(Suppl. 1), 51-59.

15. Champion, V.L., & Rawl, S.M. (2005). Secondary prevention of cancer. Seminars in Oncology Nursing, 21(4), 252-259.

The prevalence and types of sexual dysfunction in people with cancer, from the National Cancer Institute's PDQ on sexuality and reproductive issues


Sexuality is a complex phenomenon that incorporates biologic, psychologic, interpersonal, and behavioral dimensions. It is important to recognize a wide range of normal sexual function. Ultimately, sexuality is defined by each patient and his/her partner within a context of factors such as gender, age, personal attitudes, and religious and cultural values.

Many types of cancer and cancer therapies are associated with sexual dysfunction. Across sites, estimates of sexual dysfunction after various cancer treatments have ranged from 40 to 100 percent post treatment.(1)  Research suggests that about 50 percent of women who have had breast cancer experience long-term sexual dysfunction (2,3) as do a similar proportion of women who have had gynecologic cancer.(4)

For men with prostate cancer, erectile dysfunction (erections inadequate for intercourse) has been the primary form of sexual dysfunction investigated. Prevalence rates of erectile dysfunction have varied. In general, those studies that have used patients' self-reports have found higher rates of erectile dysfunction ranging from 60 to 90 percent after radical prostatectomy and between 67 and 85 percent following external-beam radiation therapy.(5-8) Erectile dysfunction appears to be least prevalent with brachytherapy and most prevalent when cryotherapy is used to treat localized prostate cancer.(9)

For Hodgkin's lymphoma and testicular cancer, 25 percent of people who have had these cancers are left with long-term sexual problems. (3,10) Several articles summarize the literature on sexuality and cancer, with a particular emphasis on cancer sites that have a direct impact on sexual functioning.(11-13)

An individual's sexual response can be affected in a number of ways, and the causes of sexual dysfunction are often both physiological and psychological. The most common sexual problems for people with cancer are loss of desire for sexual activity in men and women, erectile dysfunction in men, and dyspareunia (pain with intercourse) in women. (3) Men may also experience anejaculation (absence of ejaculation), retrograde ejaculation (ejaculation going backward to the bladder), or the inability to reach orgasm. Women may experience changes in genital sensations due to pain or a loss of sensation and numbness, as well as a decreased ability to reach orgasm. Loss of sensation can be as distressing as painful sensation for some individuals. (14) In women, premature ovarian failure as a result of chemotherapy or pelvic radiation therapy is a frequent antecedent to sexual dysfunction, particularly when hormone replacement is contraindicated because the malignancy is hormonally sensitive. (2) Most often, orgasm remains intact for men and women, though it may be delayed secondary to medications and/or anxiety.

Unlike many other physiological side effects of cancer treatment, sexual problems do not tend to resolve within the first year or two of disease-free survival;(2,7,15-19) rather, they may remain constant and fairly severe. Although it is unclear how much sexual problems influence a survivor's rating of overall health-related quality of life, these problems are clearly bothersome to many patients and interfere with a return to normal post-treatment life. In a qualitative study of 48 men (130 approached) with erectile dysfunction after treatment for prostate cancer, quality of life was significantly affected, including areas such as the quality of sexual intimacy, everyday interactions with women, sexual fantasy life, and perceptions of their masculinity. Patients who participated in a randomized trial that compared radical prostatectomy with watchful waiting were asked to complete a questionnaire regarding symptoms, psychological functioning, and quality of life. Although the frequency of sexual thoughts was similar in both groups, the prevalence of erectile dysfunction (changes in voluntary erection in sexual situations, erection on awakening, and spontaneous erections) was higher in the radical prostatectomy group (80 percent) than in the watchful-waiting group (45 percent). Among men who underwent radical prostatectomy, 56 percent were moderately or greatly distressed by the decline in sexual function, as compared with 40 percent of men in the watchful-waiting group. (20,21) Assessment, referral, intervention, and follow-up are important for maximizing quality of life and survival. (2,17)

References

  1. Derogatis LR, Kourlesis SM: An approach to evaluation of sexual problems in the cancer patient. CA Cancer J Clin 31 (1): 46-50, 1981 Jan-Feb.
  2. Ganz PA, Rowland JH, Desmond K, et al.: Life after breast cancer: understanding women's health-related quality of life and sexual functioning. J Clin Oncol 16 (2): 501-14, 1998.
  3. Schover LR, Montague DK, Lakin MM: Sexual problems. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1997, pp 2857-2872.
  4. Andersen BL: Quality of life for women with gynecologic cancer. Curr Opin Obstet Gynecol 7 (1): 69-76, 1995.
  5. Walsh PC, Epstein JI, Lowe FC: Potency following radical prostatectomy with wide unilateral excision of the neurovascular bundle. J Urol 138 (4): 823-7, 1987.
  6. Talcott JA, Rieker P, Clark JA, et al.: Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol 16 (1): 275-83, 1998.
  7. Smith DS, Carvalhal GF, Schneider K, et al.: Quality-of-life outcomes for men with prostate carcinoma detected by screening. Cancer 88 (6): 1454-63, 2000.
  8. Stanford JL, Feng Z, Hamilton AS, et al.: Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 283 (3): 354-60, 2000.
  9. Robinson JW, Moritz S, Fung T: Meta-analysis of rates of erectile function after treatment of localized prostate carcinoma. Int J Radiat Oncol Biol Phys 54 (4): 1063-8, 2002.
  10. Arai Y, Kawakita M, Okada Y, et al.: Sexuality and fertility in long-term survivors of testicular cancer. J Clin Oncol 15 (4): 1444-8, 1997.
  11. Auchincloss SS: Sexual dysfunction in cancer patients: issues in evaluation and treatment. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 383-413.
  12. Lamb MA: Sexuality and Sexual Functioning. In: McCorkle R, Grant M, Frank-Stromborg M, et al., eds.: Cancer Nursing: A Comprehensive Textbook. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1996, pp 1105-1127.
  13. Ofman US, Auchincloss SS: Sexual dysfunction in cancer patients. Curr Opin Oncol 4 (4): 605-13, 1992.
  14. Havenga K, Maas CP, DeRuiter MC, et al.: Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer. Semin Surg Oncol 18 (3): 235-43, 2000 Apr-May.
  15. Fossä SD, Woehre H, Kurth KH, et al.: Influence of urological morbidity on quality of life in patients with prostate cancer. Eur Urol 31 (Suppl 3): 3-8, 1997.
  16. Helgason AR, Adolfsson J, Dickman P, et al.: Factors associated with waning sexual function among elderly men and prostate cancer patients. J Urol 158 (1): 155-9, 1997.
  17. Litwin MS, Hays RD, Fink A, et al.: Quality-of-life outcomes in men treated for localized prostate cancer. JAMA 273 (2): 129-35, 1995.
  18. Relander T, Cavallin-Stähl E, Garwicz S, et al.: Gonadal and sexual function in men treated for childhood cancer. Med Pediatr Oncol 35 (1): 52-63, 2000.
  19. Broeckel JA, Thors CL, Jacobsen PB, et al.: Sexual functioning in long-term breast cancer survivors treated with adjuvant chemotherapy. Breast Cancer Res Treat 75 (3): 241-8, 2002.
  20. Steineck G, Helgesen F, Adolfsson J, et al.: Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 347 (11): 790-6, 2002.
  21. Bokhour BG, Clark JA, Inui TS, et al.: Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction". J Gen Intern Med 16 (10): 649-55, 2001.
     

Timely Cancer Diagnosis Linked to Insurance Status


by Steven Reinberg, HealthDay Reporter

People who either have no health insurance or rely on Medicaid are more likely to be diagnosed with advanced cancers than people who have private health insurance, researchers from the American Cancer Society report.

At a time when more than 47 million Americans have no health insurance, the new study clearly shows the effect health insurance has on the timely diagnosis of cancer.

This finding follows an earlier study from the American Cancer Society that showed uninsured patients with cancer were 60 percent more likely to die than insured cancer patients.

"Having financial barriers to health care, based on insurance status, is having a significant impact on our efforts to reduce the toll of cancer," said Elizabeth Ward, director of surveillance research in the department of epidemiology and surveillance research at the American Cancer Society.

"We could make considerable progress in reducing cancer mortality if we could ensure that financial barriers, such as lack of health insurance, did not prevent people from getting recommended cancer screening and access to health care when they have symptoms," Ward added.

In the study, Ward's team used the National Cancer Database, which includes data from 1,430 medical facilities and information on 73 percent of cancer patients in the United States. The current study looked at patients aged 18 to 99 who were diagnosed with any of 12 cancers between 1998 and 2004.

There was a consistent relationship between insurance coverage and the stage at which cancer was diagnosed. Uninsured patients were significantly more likely to be diagnosed with advanced cancers compared with patients who were privately insured, the researchers found.

The two cancers that were most likely to be diagnosed in advanced stages among the uninsured were colorectal cancer and breast cancer.

In addition, Medicaid patients also had an increased risk of being diagnosed with advanced cancer, Ward's group found.

For both Medicaid patients and uninsured patients, cancers that are routinely screened for were the most likely to be diagnosed in an advanced stage. This was also true for cancers that present with symptoms in the earliest stages, such as melanoma and bladder cancer.

Cancers such as pancreatic and ovarian cancer tended to be diagnosed in later stages, regardless of whether the patient was insured, uninsured or on Medicaid. These cancers are typically found in an advanced stage since there are no screening tests that could find them early, Ward noted.

In addition, blacks were more likely to be diagnosed with advanced cancers. This finding shows that barriers to screening tests and health care beyond insurance negatively affect black patients, the researchers suggest.

The American Cancer Society thinks that the health-care system in the United States needs to be reformed, Ward said. "There needs to be a process of really looking at the problems with the way the health insurance system is working. There needs to be a dialogue about how to make this better," she said.

References

Reinberg S. Timely Cancer Diagnosis Linked to Insurance Status. HealthDay News; 18 February 2008.

Halpern M, Ward E, Payluck A et al. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncology DOI:10.1016/S1470-2045(08)70032-9; 18 February 2008.

How important is exercise for cancer survivors?


by Lexi Harlow, Physical Therapy, Seattle Cancer Care Alliance

Very important! The American Cancer Society recommends a physically active lifestyle, along with an appropriate weight and healthful diet, to prevent recurrence, second primary cancers, and other chronic diseases.1 Studies have shown that exercise improves cardiovascular fitness, muscle strength, body composition, fatigue, anxiety, depression, self-esteem, happiness, and quality of life in cancer survivors.2 Often, survivors tend to decrease their physical activity levels after being diagnosed with cancer and most continue lower levels of activity through treatment and beyond increasing their overall risk for a second cancer, obesity, diabetes, and/or heart disease.1 Most, if not all, cancer survivors would benefit from a consultation by a physical therapist to help develop a comprehensive exercise program.

Physical therapists can make recommendations on the type, frequency, duration, and intensity of exercise. This exercise program should be individualized to your age, diagnosis, treatment, previous activity level, and other medical conditions. Physical therapists can evaluate specific needs in the following areas: strength, flexibility, cardiovascular re-training, scar tissue work after mastectomy/lumpectomy, fatigue, balance, incontinence and neuropathy disorder treatment and to teach lymphedema prevention and/or treatment education.

How can we help you start a safe exercise program?
The Seattle Cancer Care Alliance has physical therapists on staff with expertise in recommending specific exercise programs to cancer survivors with a wide variety of diagnoses and stages of treatment. If you are interested in meeting with a physical therapist at the SCCA, please discuss this further with your doctor, who can make a referral to our department. Survivors who are seen in the Survivorship Program's MOST Clinic can receive a comprehensive evaluation, which will include a discussions of the benefits of exercise and any possible risks. We can also refer you to one of our physical therapists for a consultation. We look forward to helping you meet your physical fitness goals and enhancing your quality of life as a cancer survivor.

For more information on the Fred Hutchinson Cancer Research Center Survivorship Program, or to arrange an appointment for yourself, a friend or family member, call 1-866-543-4272, e-mail us at survivor@fhcrc.org. We hope to hear from you soon.

References


1Doyle C, Kushi LH, Byers T, et al. Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices. CA Cancer J Clin 2006; 56; 323-353.
 

2Courneya KS. Exercise in cancer survivors: an overview of research. Med Sci Sports Exerc 2003; 35: 1846-1852.

  

Health and employment in young adult survivors of childhood cancer

In a study of nearly 10,400 adult survivors of childhood cancer, more than 6 percent had at least one chronic condition and 28 percent had a severe or life-threatening health problem. The survivors were more than three times as likely as their siblings to have a chronic health condition, and women were at greater risk than men. Survivors of bone tumors, central nervous system tumors and Hodgkin lymphoma had the highest risk of a serious chronic condition. Childhood cancer survivors need lifelong follow-up focused on prevention, early detection and treatment of these health problems. The authors of this study include our Survivorship Program director, Dr. Debra Friedman.

In another study of the same adult survivors, 5.6 percent reported never having been employed compared with 1.2 percent of their siblings. Females and those younger than age 4 at the time of childhood cancer treatment were at greatest risk. Survivors of bone tumors, central nervous system and those treated with higher doses of radiation therapy to the brain had the highest risk. (Pang JWY et al. Pediatric Blood and Cancer. 2007 In Press)

Most Cancer Survivors Return to Work

Living Productively Enhances Self-Esteem

(Reprinted by the permission of the American Cancer Society, Inc. from www.cancer.org. All rights reserved.) Today there are more cancer survivors than ever, thanks to improvements in early diagnosis and treatment. For young and middle-aged survivors, returning to work is vital for financial and social well-being, as well as for self-esteem, researchers said.

A recent Dutch study reported in Psycho-Oncology (Vol. 11: 124-131) looked at factors related to cancer survivors and their return to work. The study looked at survivors in North America and the Netherlands.

Returning to work is not only important to cancer survivors, but to the whole society as well, said Evelien R. Spelten, PhD, at the Academic Medical Center in Amsterdam.

Quality of Life Improves With Return to Work Spelten and her colleagues focused on 14 studies conducted between 1985 and 1999 to find out how many cancer survivors stay in the work force, and what factors are related to their return to work.

In the studies reviewed, Spelten found the average time of return after diagnosis or the end of treatment ranged from less than one year to eight years. She found that if more time had passed since the end of treatment, then the greater the return to work.

Spelten found that returning to work improved the quality of life for many cancer patients. Positive work-related factors included a supportive work environment and attitude from coworkers, as well as a flexibility of work hours and amount of work. Negative factors were associated with those jobs with physical demands.

"Interestingly, discrimination at work was not significantly related to return to work and did not seem to be a more prevalent problem among cancer survivors than in a control group," said Spelten.

Changing Attitude Towards Work a Factor
Factors affecting a cancer survivor's return to work included a changing attitude towards work. The importance of work decreased, and a "life-is-too-short" attitude was evident, said Spelton. Most of the studies found increasing age and fatigue mostly did not affect the decision to return to work.

Education, income, gender, and marital status were not associated with return to work, Spelton said.

The researchers qualified their findings by noting the scarcity of information available. They pointed out a general lack of systematic research into the return to work by cancer patients as well as information on the prevalence of cancer in the working population.

Given the increasing number of cancer survivors, the authors recommend that more research is needed.

"This information can be used to design interventions to facilitate the return to work of cancer survivors by health care workers such as nurses, clinicians, occupational physicians, psychologists, and social workers," said Spelton.