Survivorship Guidelines for Cancer Patients and Their Families

Cancer Is a Life-Changing Event!

A cancer survivor is defined as one living from the time of diagnosis, throughout the remainder of his or her life, with and beyond cancer. Understanding the long-term physical and psychosocial effects of cancer and cancer therapy can help patients and their families better deal with potential complications associated with being a cancer survivor.

Currently, there are over 1.4 million new cases of cancer diagnosed each year in the United States; by the year 2030, this number is expected to double. The National Cancer Institute (NCI) and American Cancer Society (ACS) project that about one-third of women and one-half of men will have cancer in their lifetime. One in four people are expected to die from the disease.

At the same time, the survival rate is increasing, rising from 3 million survivors fifteen years ago to over 10 million survivors in the year 2006. This rate will continue to increase with advances in diagnosis, treatment, and care. It is estimated that by 2030, there will be over 20 million survivors. Cancer has become a chronic disease.

Unfortunately, many survivors experience lasting adverse side effects of treatment. Although the current five-year survival rate is 64 percent (compared to 50 percent twenty-five years ago), the estimated follow-up needed is at least ten to twenty-plus years, the remainder of the survivor’s life. Susan Sontag’s cancer experience provides a good example of the potential for productivity, wellness, and longevity in survivorship—diagnosed and treated for metastatic breast cancer at age forty-five, she subsequently died at age seventy-one of a new cancer.

Despite advances and innovations in cancer diagnosis and treatment, the consequences for survivors remain serious. Over 50 percent of cancer survivors have residual side effects; over 25 percent experience recurrence or develop new cancers. It is estimated that 75 percent of survivors can have health deficits related to their treatment.1

There is also overwhelming evidence that “cancer patients die of noncancer causes at a higher rate than persons in the general population.”2 Added to known cancer-specific vulnerabilities, the increased risk of additional illnesses (referred to as comorbid conditions) makes the need for follow-up programs for cancer survivors even more urgent. Common comorbid conditions that threaten the lives of cancer survivors include well-known entities such as coronary artery disease, congestive heart failure, and diabetes.

Age is a major risk factor that has recently been shown to correlate to functional decline. Sixty-one percent of cancer survivors are over the age of sixty-five. In the United States, 12.4 percent of the population (35 million people) is currently over sixty-five, and this demographic is expected to double by 2030 to 70 million (20 percent). As people’s life expectancies continue to increase, a natural result is that they often must deal with more comorbidities.

Survivors are also at risk for psychological and physiologic changes, which include potential organ dysfunction, an impaired immune system, sexual dysfunction, cognitive changes, fatigue, depression, anxiety, and family distress, as well as economic challenges related to insurance, job security, and monetary survival.

 

The Challenge

The greatest of the many barriers to effective long-term survivorship care is the lack of awareness. While many cancer patients seek better ways to reduce their risk and improve their survival through better health and lifestyle practices, some patients, after completing their therapy, wish to distance themselves from their cancer and do not wish to continue in a follow-up program.

The challenge for health professionals is to provide and implement ways to improve lifestyle changes and health outcomes. Cancer survivors need to be made aware of the new conditions and risks that follow cancer and its treatment, as well as strategies they can implement to reduce their vulnerabilities. Oncologists and the medical team (primary physicians, general practitioners, nurse specialists, etc.) can play a key role in cancer detection, treatment, surveillance, and prevention for patient care. Unfortunately, only about 20 percent of oncologists actively guide survivors on better health practices and lifestyle changes. In addition, physicians often do not have access to current standards of care and clinical guidelines.

A multidisciplinary team approach and a variety of delivery systems are needed to address the medical, psychosocial, and lifestyle components of survivorship care. The American Society of Clinical Oncology (ASCO), Institute of Medicine (IOM), National Coalition for Cancer Survivorship (NCCS), and ACS are currently working together on a task force to provide specific guidelines for therapy, screening, and prevention. The following is a list of actions identified to improve health and longevity:

1. Collect statistics on comorbid health and follow-up screening of survivors, assess treatment results and quality of life, and promulgate “best practices”3

2. Collect and analyze data on disability and dysfunction due to age to identify ways to improve function and quality of life4

3. Promote better lifestyles (e.g., diet, exercise, smoking cessation, limited alcohol, and reduced sun exposure) and screening for comorbid diseases, cancer recurrence, new cancers, and comorbidities

4. Reduce and improve side effects of therapy and cancer (e.g., lymphedema, sexual dysfunction, fatigue, cognitive/memory problems, and mucositis) and late aftereffects, or sequelae (e.g., cardiac dysfunction, osteoporosis, pulmonary fibrosis, and kidney failure)

5. Improve survival by reducing comorbidities and treatment side effects (using improved treatments such as sentinel node biopsies and adjuvant therapies and new drug treatments to promote longevity, quality of life, and survival)

Recommended “Road Map” for Survivors

Healthy survivorship requires implementation of a healthy lifestyle, measures to reduce comorbid risks, and a cancer care plan with recommendations for follow-up for each patient. An ideal care plan includes a review of the patient’s medical history, diagnosis, and treatments and a set of follow-up recommendations to help guide both patient and caregivers over the next twenty-plus years with appropriate surveillance and interventions to minimize, and hopefully prevent, further problems. The patient should be provided with the following:

1. Information about potential late- and long-term side effects of cancer and cancer therapy and the possibility of recurrence or a new cancer

2. A standardized program highlighting potential future problems and prevention measures such as follow-up observational and screening programs

3. Information about lifestyle changes that can reduce the risk and severity of side effects and comorbidities

4. Psychosocial and group therapy support for anxiety, fear, isolation, and depression problems

5. A list of community resources to aid in obtaining benefits, insurance, employment protection, and life-support needs

6. Ongoing communication of new advances in medicine and current research that could help reduce the sequelae of both cancer and cancer therapy

By providing patients with a cancer care plan, oncologists make it possible for survivors to truly understand the lifelong scope of their condition and become “partners” in their medical care. Although many survivors wish to forget their cancer experience at the end of their therapy, many others need the reassurance of having a plan and knowing how to recognize what may later be side effects of their disease or its treatment.

There is no specific follow-up schedule, as each patient is different and will require different follow-up program guidelines depending on the type of cancer he or she has. However, there are generalized elements that should be included, below.

Side Effects of Cancer and Its Therapy

With the current five-year survival rate of 64 percent, the majority of cancer patients will live years and decades longer. At the same time, they face various challenges following curative or remission therapy, which in turn can affect personality, emotions, and social relations. There are also possible physical changes due to surgery, radiation therapy, chemotherapy, and immunotherapy, causing physical limitations and challenges to quality of life. While there are a number of side effects associated with cancer and its therapy that should be discussed with the physician, late effects, long-term effects, recurrence, second tumors, infertility, and fatigue are addressed below.

Late Effects Late effects of therapy involve unrecognized toxicities that occur many years posttherapy. Information about potential latent side effects of cancer therapy can arm survivors with knowledge and a plan. By providing and promoting lifestyle interventions, it is possible to reduce the rate of current and late comorbidities and adverse therapy related to toxic side effects.

Often, there may be changes that occur months or years after treatment. An example of this is heart problems following therapy with drugs such as doxorubicin (Adriamycin) and trastuzumab (Herceptin). Research is ongoing to evaluate better and safer treatments and also ways of coping with and reducing these delayed side effects.

Many times, late complications from toxic side effects of therapy not only bring back fears and physical problems, but also may require specialized treatments and care to help improve and ameliorate these symptoms. For example, thyroid failure (hypothyroidism) can occur years following neck radiation involving the thyroid gland. Knowing that this could happen can help reduce anxiety by assuring the patient that this is not a recurrence of the cancer, but a delayed side effect from treatment.

Long-Term Effects Long-term effects are side effects or complications of therapy that persist when therapy is completed, requiring patients to develop compensatory treatment programs to relieve or control these symptoms. This is in contrast to late effects, which occur months or years posttreatment.

For example, peripheral neuropathy (pain, numbness, tingling, loss of sensation, or heat or cold sensitivity in the extremities or the body) is often a long-term side effect in patients receiving particular chemotherapy agents such as platinum compounds (carboplatin [Paraplatin], cisplatin [Platinol], oxaliplatin [Eloxatin]), vincristine (Oncovin), and taxanes (paclitaxel [Taxol], docetaxel [Taxotere]). Surgery, radiation, or chemotherapy can cause damage to vital organs, such as the heart, lungs, kidneys, and gastrointestinal tract. Older persons over the age of sixty-five may have preexisting heart, lung, kidney, gastrointestinal, or liver problems that are exacerbated by anticancer therapy, as these organs may be more susceptible to side effects from treatment.

Cardiac dysfunction problems can occur early or late with anthracycline drugs, including doxorubicin (Adriamycin), daunorubicin (Cerubidine), epirubicin (Ellence), and mitoxantrone (Novantrone). Long-term follow-up is recommended for possible congestive heart failure up to twenty-plus years after treatment. For those who already have cardiac problems, radiation to the heart and treatment with these drugs can also cause progressive cardiac problems. Protective drugs are being developed to delay or prevent damage. In addition, lifestyle changes of diet and exercise are important for promoting better health and disease prevention.

Platinum compounds can cause decrease in kidney function, and this can also be accentuated when there is abdominal radiation involving the kidneys. Platinum compounds can also cause high-frequency hearing loss. For those receiving radiation therapy to the head, common problems may include cataracts, dry eyes, and dry mouth. Abdominal radiation can cause chronic diarrhea, malabsorption, milk/lactose intolerance, bowel dysfunction, and weight loss.

Recurrent and Second Tumors Survivors also need to be followed for many years for the possibility of developing either a recurrence of their original cancer or a completely separate, second primary cancer relating to their prior therapy. It’s been estimated that up to 25 percent of patients may face a problem such as bone marrow failure, myelodysplasia (bone marrow dysfunction), or a new cancer. Lifestyle practices can be helpful in reducing the risk of comorbid conditions and possibly second cancers or delayed recurrences.

Fertility Problems Infertility is a serious concern for patients wishing to have children. Infertility can occur with patients receiving radiation to the testes. However, it has been noted that hormone levels in irradiated children usually remain normal as they go through puberty. Radiation to the abdomen and chemotherapy may also affect the reproductive organs (ovaries or testes), resulting in infertility. While chemotherapy can cause infertility, not all drugs have this effect. The alkalating agents, such as nitrogen mustard (Mustargen), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and ifosfamide (Ifex), have been implicated, but the effects depend on the dose and administration of the drugs. Methods to preserve fertility are therefore an important consideration for those wishing to have children.

Fatigue Fatigue is one of the major problems during therapy and posttherapy, requiring an active program for fatigue reduction. Both rest and exercise help in controlling debility and fatigue problems. In addition to treatment effects, fatigue can be caused by emotional stress, anxiety, depression, pain, and problems sleeping, as well as a hormonal problem such as hypothyroidism (low thyroid function) or anemia due directly to cancer or as a result of treatment.

Preventive Measures

It is as important to make and implement positive recommendations for cancer prevention as it is to diagnosis and treat cancer. Given the increase in risk of developing side effects and comorbidities, as well as the potential recurrence of other cancers, prevention measures are critical for the cancer survivor.

Consensus guideline templates are being developed to promote wellness and quality of life, from the time of diagnosis through the current standard of five years’ surveillance posttreatment and into long-term follow-up for ten to twenty-plus years beyond that.

Follow-up care is essential and in reality will most likely be delivered by primary care physicians or a nursing team. There is a need for experience in long-term follow-up for chronic conditions, even for individuals who seem to have recovered completely from their cancer and associated treatment.

The three levels of prevention are described below with examples pertinent to cancer survivors. The patient’s cancer care plan should provide a detailed list of recommended screening tests and frequency, as well as suggestions for staying healthy.

Primary Prevention Primary prevention refers to lifestyle changes aimed at preventing cancer from occurring. Examples include a prudent-type diet, smoking cessation, reduction of alcohol use, reduction of sun exposure, and exercise.

Secondary Prevention Secondary prevention involves implementing screening programs to detect cancer at its earliest stages, usually before a person notices anything wrong (e.g., screening tools for cervix, breast, colon, prostate, and skin cancers). This includes vigilance in detecting secondary malignancies after original cancer therapy (e.g., increased risk for breast cancer many years following chest mantle radiotherapy for Hodgkin’s disease therapy merits long-term follow-up for detection of breast cancer at its earliest stages). Additionally, secondary prevention involves early detection of nonmalignant conditions that may result from cancer treatment, such as osteoporosis.

Tertiary Prevention Tertiary prevention is directed toward individuals who already have a disease (e.g., cancer), to prevent further damage, pain, and debility and to improve their overall functional status. This includes management of late and long-term toxicities related to cancer therapy. Examples include using drugs such as dexrazoxane (Zinecard) to reduce the risk of cardiac toxicity from anthracyclines; administration of bisphosphonates for patients with bony metastases to reduce the risk of fractures and other skeletal complications; and optimizing pain management in patients with pain due directly to their cancer or as a result of cancer treatment.

Lifestyle Changes

A cure does not mark the end of the healing process. Sometimes, it is a difficult transition from the state of illness to the state of well-being. While the goal is to resume as normal a life as possible, there are major changes following the crisis of a cancer diagnosis and treatment. Physical, psychological, and social problems may come to light or persist following the completion of cancer treatment.

To promote better health and reduce the risk of premature morbidity and mortality, survivors need to improve both the physical and emotional quality of life. Thus, it is necessary that survivors acquire and adopt lifestyle changes to help reduce the risk of future morbidity. As patients grow older, new risk factors are constantly evolving that require new solutions, constant vigilance, and care.

Functional status deteriorates during cancer therapy but usually recovers posttherapy with time. Older cancer patients who have one comorbidity have twice the risk of experiencing functional debility; with two comorbidities, the risk increases fivefold. Some of the problems survivors face after surgery, chemotherapy, and/or radiation therapy include a decrease in immune functioning, cardiopulmonary toxicity, and, in many cases, weight gain.

The diagnosis of cancer not only poses a challenge for survivors, but also necessitates many changes in lifestyle for both the patient and the family. Improving lifestyles reduces comorbid health risks and can help reduce therapy side effects. Preventive and healthy activities should be implemented, including psychosocial support, a healthy diet, exercise, sun protection, osteoporosis prevention, smoking cessation, and alcohol abstinence. Physicians and nurse specialists are best situated to recommend the screening and preventive medicine programs that will promote a better quality of life for posttherapy cancer patients.

Adopting a Prudent Diet Diet modifications made post–cancer diagnosis are common in 30 to 60 percent of survivors. These changes generally include decreased consumption of red meat, saturated fat, and trans fats and increased consumption of fruits, vegetables, and whole grains. Decreased calorie intake combined with increased exercise is important for weight control, longevity, and survival.

In particular, survivors need to acknowledge lifestyle dangers and changes due to obesity. Obesity increases the risk for diabetes, cardiovascular disease, and certain cancers, including breast (postmenopausal), prostate, colon, kidney, esophagus, and endometrial cancers. In fact, 20 to 30 percent of cancers in the United States can be attributed to obesity and lack of exercise. In addition, the diseases associated with obesity, diabetes, and cardiovascular disease are responsible for an increased number of non-cancer-related deaths among survivors. In survivors, fully one-half of non-cancer-related deaths are related to noncancer comorbidities.

The proportion of newly diagnosed obese cancer patients is increasing, as is the number of patients who gain weight during therapy and post–cancer therapy. Thus, weight control through diet and exercise is crucial for healthy survivorship. Survivors need to work toward the goal of a body mass index (BMI—weight [kg] divided by height [meters] squared and multiplied by 703) of less than 25 to avoid obesity. Unfortunately, older males and people who are less educated are less likely to adopt changes necessary to avoid obesity. It has been estimated that only 25 percent to 42 percent of survivors consume adequate amounts of fruits and vegetables, and that 70 percent of breast and prostate cancer survivors are overweight or obese.

Diabetes is also a common, chronic disease in cancer survivors. It can lead to eye disease, kidney disease, and nerve damage and is a risk factor for cardiovascular disease. Most people with diabetes are overweight and have type 2 diabetes, or non-insulin-dependent diabetes mellitus. Although excellent control of blood sugar levels can decrease the risk of the above complications, prevention of this type of diabetes through lifelong diet modification with exercise remains the best option for a healthy life.

A prudent diet that will help prevent obesity and diabetes, as well as potentially increase longevity, is all of the following:

• A well-balanced diet.

• A low-fat diet (less than 25 percent fat calories).

• Limit saturated fats to 8 percent of calories.

• Decrease animal fats and processed meats.

• Increase fish intake.

• Use low-fat dairy foods.

• A high-fiber diet (30 to 35 g per day).

• Increase whole-grain foods (breads and cereals).

• A variety of eight to ten portions of fruits and vegetables daily.

• Increase cruciferous vegetables (e.g., broccoli, cauliflower, turnips, and kale).

In addition, limit salt-cured, smoked, and nitrate-cured foods, as well as fried and barbecued foods. Alcohol should also be limited to one or two drinks a day.

Exercise Exercise plays a key role in reducing cancer risk and can be very beneficial in promoting survival and longevity. Exercise is correlated with improved quality of life, improved physical functioning (oxygen capacity, strength, flexibility, and general health), and improved blood pressure, heart rate, and circulating-hormone-level control. It is now well established that for breast and prostate cancers, exercise helps promote longevity and potentially disease control. The risk reduction has been confirmed in many studies, which also provide an understanding of the physiological mechanisms by which exercise effectively reduces breast and prostate cancer risk, as well as fatigue, and improves quality of life.

Exercise helps reduce obesity and not only improves long-term health, but also reduces the risk of several comorbid conditions, including disease progression, possible second primary cancers, osteoporosis, cardiovascular disease, diabetes, and functional physical decline.

Exercise is a vital component to losing weight. Aerobic exercise is the most effective and involves rhythmical use of the large muscles of the legs and arms to elevate the heart rate within a certain range. Examples are brisk walking, jogging, swimming, bicycling, gardening, dancing, playing actively with children, and sexual activity.

Preexisting comorbidities (arthritis, cardiovascular disease, chronic obstructive pulmonary disease) may limit physical and social functioning. For survivors with these conditions, alternate exercise programs such as tai chi, qi gong, and yoga can help promote muscle strength, flexibility, coordination, balance, and body function. Also, tai chi has been shown not only to improve health-related quality of life, balance, and self-esteem, but also to contribute to prolonged longevity. Tai chi also promotes psychosocial support for improving health-related quality of life.

Physical-activity programs help improve cardiorespiratory fitness during and after treatment and at the same time help lessen fatigue and promote improved vigor with better quality of life and less depression and mental distress.

Tobacco in Survivors The use of tobacco is diminishing. Fewer cigarettes were sold in 2005 than in 1951, and more places are now designated as nonsmoking areas. There are now more nonsmokers than smokers.

Unfortunately, however, more children in the eighth grade are now smoking. Quitting rates for lung and head and neck cancer survivors are about 40 percent versus about 4 percent for breast cancer patients. Sadly, younger survivors often continue to smoke. Smoking has been causally related to lung, bladder, head and neck, cervix, kidney, and esophagus cancers, as well as cardiovascular disease and chronic obstructive pulmonary disease.

Cessation efforts are necessary for survivors. Even five minutes of a physician’s advice on how to stop smoking can be very critical in a patient’s success.

Alcohol in Survivors In over 100 studies, alcohol has been shown to be a small to modest cancer risk factor, where one drink a day increases the risk 8 to 10 percent and two drinks a day may increase the risk up to 25 percent.

Research suggests that the effect of alcohol on breast cancer risk is greater in postmenopausal women with estrogen-positive tumors. How and why this is remains unknown at this time but may be related to increased estrogen levels. Alcohol increases the need for folic acid; thus 400 mcg per day is suggested for those who consume alcohol.

The majority of habitual alcohol drinkers do not eat a nutritious diet, resulting in an additional health deficit. The alcohol abstinence rate for head and neck cancer survivors is about 50 percent; for breast and lung cancer survivors, the abstinence rate is 8 to 16 percent.

Reducing Sun Exposure Excess sun exposure can damage the skin, causing premature aging and sometimes leading to various forms of skin cancer. A skin protection program is vital.

Preventing Osteoporosis Loss of ovarian or testicular function may also contribute to osteoporosis by decreasing hormone levels (estrogen or testosterone) with subsequent bone weakness and/or fractures. This problem necessitates the use of calcium, vitamin D, hormonal replacement therapy (estrogen or testosterone), and possibly biphosphonate therapy.

Short- and Long-Term Psychological Effects

All patients and survivors not only have medical problems from cancer and its therapy, but also have emotional and social well-being challenges. The stress of coping with a cancer diagnosis ranges from mild to severe, often depending on the severity of the diagnosis and treatment and the prior mood of survivors. A third or more of patients report psychological distress during the early months of treatment.5,6,7 The prevalence of psychological distress in one study of 4,496 cancer patients at the Johns Hopkins Kimmel Cancer Center was 35 percent.8

Mood usually improves over time for many survivors.9 Although some patients adjust their lives and actually feel better, others have anxiety, depression, and feelings of isolation, as well as problems interacting with friends and family. Subgroups of survivors remain vulnerable to distress or depression for a long period of time. Clinical depression affects 18 to 21 percent of survivors at various points of time.10,11 Cancer survivors who were depressed prior to their diagnosis are at a heightened risk for shortened survival time.12

Cancer survivors are vulnerable to both acute and post-traumatic stress, a result of the life threat and loss of control experienced following diagnosis and treatment. These responses are similar to those of the acute and post-traumatic stress syndromes seen in soldiers on the battlefront or returning from war, or among those who have experienced extreme psychological or physical problems.

Clinical evaluation, counseling, and educational programs offered immediately postdiagnosis and following treatment can reduce stress and lead to a better adjustment to the consequences of having cancer and receiving therapy. The cancer center at Stanford University (where the authors work), for example, has been a leader in offering group support, individual counseling, massage, medical qi gong, tai chi, restorative yoga, healing and guided imagery, expressive art and imagery, creative writing, healing touch, and exercise. Educational programs are provided, such as Managing and Understanding Your Chemotherapy and Look Good … Feel Better, as well as nutritional consultations. Group therapies are provided for patients with breast, brain, ovarian, and colorectal cancers, leukemia and lymphoma, and multiple diagnoses, and for husbands of women with cancer.

Psychological Support

Patients facing a diagnosis and treatment for cancer often have anxiety, depression, psychological distress, loss of control, and fear. These emotions are better controlled with psychological support such as individual counseling and group therapy.

Psychosocial Spiritual and Religious Support

It is of interest that an association between spirituality and improved survival has been observed in some studies. Cardiovascular research has shown that patients who gain comfort and strength from religion and/or spirituality and who participate in social and community groups have a lower mortality rate during the six months following cardiac surgery than those who are lacking in these categories.

In a recent article in the Mayo Clinic Proceedings, Edward Creagan, M.D., wrote that “cancer survivors may be spared for reasons that are not clearly understood,” and that “among the coping methods of long-term cancer survivors, the predominant strategy is spiritual. It is still recognized that the biology of a cancer is the most important determinant in the life history of a cancer course, but it is now becoming recognized that religion or spirituality may also influence the course of the cancer.”13

Community Resources Many people do not understand that cancer is not contagious, and their fears may be transmitted and cause problems for cancer survivors in the work area. Misconceptions and prejudices can influence how employers and coworkers treat survivors. The fear that a worker will be less productive has been refuted. In a study by MetLife Insurance and Bell Telephone, a survivor’s job performance showed no difference when compared to nonsurvivors. In fact, survivors often work harder to prove their worth.

As a cancer survivor, you need to look at changes directed by superiors at the job, often because of fears that responsibilities cannot be effectively met. There is a social readjustment with coworkers and superiors, who may treat you differently or not promote you as merited. Keeping notes on these problems is important: If you are discriminated against and legal action is necessary, you will need documentation.

The Americans with Disabilities Act of 1990 makes it illegal to discriminate against any qualified applicant who is disabled, has a history of disability, or is perceived to have a disability. Thus, survivors have recourse if they have legitimate complaints (Equal Employment Opportunity Connection, 1801 L Street, NW, Washington, D.C., 20507).

A good resource is the National Coalition for Cancer Survivorship, Silver Springs, Maryland (canceradvocacy .org).

More information is also available in

• the Institute of Medicine/National Research Council report From Cancer Patient to Cancer Survivor, Lost in Transition, published in November 2005, and

• A Cancer Survivor’s Almanac: Charting Your Journey by Barbara Hoffman, J.D., National Coalition for Cancer Survivorship, published in 2004.

These two references also have extensive information about health insurance and employment issues for survivors.

Additional information can be found at www.cancersupportivecare .com and www.canceradvocacy .org.

Notes

1. Haylock PJ. The shifting paradigm of cancer care. Nurs 2006;106(3) supplement:16–19.

2. Brown BV, Brauner MC. Noncancer deaths in white adult cancer patients. J Natl Cancer Inst 1993;85:979–97.

3. Hewitt M, Greenfield S, and Stovall E, eds. From Cancer Patient to Cancer Survivor, Lost in Transition. Washington, D.C: The National Academies Press, 2005.

4. Sweeney C, Schmitz KH, Lazovich D, et al. Functional limitations in elderly female cancer survivors. J Natl Cancer Inst 2006;98(8):521–9.

5. Bodurka-Bevers D, Basen-Engquist K, Carmack CL, et al. Depression, anxiety, and quality of life in patients with epithelial ovarian cancer. Gynecol Oncol 2000;78(3 Pt 1):302–8.

6. Trask PC, Paterson A, Riba M, et al. Assessment of psychological distress in prospective bone marrow transplant patients. Bone Marrow Transplant 2002; 29(11):917–25.

7. Carlson LE, Angen M, Cullum J, et al. High levels of untreated distress and fatigue in cancer patients. Br J Cancer 2004;90(12):2297–304.

8. Zabora J, Brintzenhofeszoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psychooncology 2001;10(1):19–28.

9. Ganz, PA, Desmond KA, Leedham B, Rowland JH, Meyerowitz BE, Belin TR. Quality of life in long-term, disease-free survivors of breast cancer: A follow-up study. J Natl Cancer Inst2002;94(1):39–49.

10. Bodurka-Bevers D, Basen-Engquist K, Carmack CL, et al. Depression, anxiety, and quality of life in patients with epithelial ovarian cancer. Gynecol Oncol 2000;78(3 Pt 1):302–8.

11. Fobair P, Hoppe RT, Bloom J, Cox R, Varghese A, Spiegel D. Psychosocial problems among survivors of Hodgkin’s disease. J Clin Oncol 1986;4(5):805–14.

12. Brown KW, Levy AR, Rosberger Z, Edgar L. Psychological distress and cancer survival: A follow-up 10 years after diagnosis. Psychosom Med 2003;65 (4):636–43.

13. Creagen ET. Attitude and disposition: Do they make a difference in cancer survival? Mayo Clin Proc 1997;72(2):160–4.