According to the American Cancer Society (ACS), almost one-third of women in the United States will develop cancer. Most of these women will survive their cancer diagnosis yet face an uphill battle of maintaining their health as well as to reduce the risk of cancer recurrence. To help women in coordinate, there is a shift toward patient-centered approaches to survivorship with Clinical Integrated Networks (CIMs), Patient-Centered Medical Homes (PCMHs), Accountable Care Organizations (ACOs), and the Patient-Centered Outcomes Research Institute (PCORI; Figure 21-1). The focus of these emerging concepts is to help women make informed health care decisions, improve health care delivery, and implement plans of care using evidence-based information. Ultimately, survivorship is guided by patients, caregivers, and the broader health care community.1 Ideally, patients as well as members of the public have the information they need to make decisions with their health care professional that reflect desired health outcomes. As health care professionals, we must hear the call of our patients’ desires to improve survivorship through rehabilitation, quality of life (QOL), and symptom management. As the nation moves from physician-centric care to a patient-centered team approach, our patients deserve more active roles in their survivorship.
Approach to patient care with the dawn of health care reform.
Cancer survivorship can be improved by participating in rehabilitation, improving QOL, and managing symptoms. With new national guidelines putting the patient at the center of communication between oncologists and primary care providers, we need to ensure all survivorship options are available to them.
Gynecologic cancer diagnosis can play havoc on a woman’s body. Oncologists typically use various conventional therapies for treating gynecologic cancers to facilitate a positive prognosis. Unfortunately, these therapies along with a list of comorbidities can reduce the functional ability and QOL of women in survivorship. Rehabilitation is defined as restoring the body for use in life. Oncology rehabilitation specifically addresses a patient’s debilitating adverse events as a result of the therapeutic interventions.2 Evidenced-based oncology rehabilitation includes physical strengthening, flexibility, functional assessments, QOL improvement strategies, stress management, lifestyle changes, and nutrition/dietary interventions. While still fairly new, oncology rehabilitation is still underutilized as a tool in survivorship, even as we face a future of patient-centered health care.
Although the potential benefits of oncology rehabilitation are obvious, the optimal frequency, intensity, type, and timing of rehabilitation for patients undergoing treatment or in survivorship still remain unclear.3,4,5,6 Clinicians struggle to find the balance of challenging gynecologic cancer survivorship and encouraging one to make lifestyle changes all at once. However, can patients really afford to be inactive? Encouraging patients to be physically active can improve glucose metabolism, digestive function, immune function, and cardiovascular risk factors.7,8 The balancing act between cancer recovery and thriving in survivorship can be tricky. Nevertheless, the literature remains clear that physical activity/rehabilitation is necessary to reduce the decline of a patient’s health status and support a full recovery. In fact, several health care practitioner groups have developed oncology survivorship-specific toolkits to help serve as guidance documents to ensure the well being of patients with cancer. These toolkits highlight the conventional approaches to rehabilitation for improving physical capacity as well as encouraging healthy lifestyles. Regardless of the cancer diagnosis, exercise/physical activity is the most important thing that a survivor can do in reducing cancer-related fatigue, cancer-related stress, and reoccurrence.9
The American Physical Therapy Association (APTA) provides basic guidelines for treating the adult cancer survivor (Table 21-1). Mainly, the plan of care includes improving physical function (metabolic equivalents of tasks [METs]) during or after various treatments of cancer. Typically, a multisystem approach of improving cognitive, physical, and psychosocial arenas of a patient’s life is also included in the standard plan of care. Specifically, oncology rehabilitation can be beneficial to gynecologic oncology patient at any place on the spectrum of survivorship in various settings of outpatient or inpatient venues.10 These highly specialized rehabilitation programs have produced promising outcomes in reducing symptoms and in improving physical and psychosocial functioning.11,12 For example, in a recent Cochrane review on the effects of rehabilitation and cancer-related fatigue,13 56 studies demonstrated a significant impact on the aerobic system and reducing fatigue for patients undergoing oncology rehabilitation compared to controls. However, evidence for increased muscle strength was not significant in regards to overall resistance training and other alternative exercises. Alternatively, targeted resistance training such as strengthening the pelvic floor muscles after pelvic surgery due to gynecologic cancer has been shown to improve muscle strength, QOL, and urethral function. In a prospective, randomized, controlled trial of pelvic-floor exercises (PFRPs) in gynecologic cancer survivors, the intervention group significantly improved pelvic-floor function and QOL domains.14 The PFRP program consisted of one 45-minute exercise session and a 30-minute counseling session per week for 4 weeks. Overall, the stance of the APTA is to optimize activity by improving functional METs with reduced perception of fatigue allowing for improved activities of daily living (ADLs), knowledge through education, range of motion, and general strength training for ADLs.
Table 21-1.Summary of oncology rehabiltation guidelines. ||Download (.pdf) Table 21-1. Summary of oncology rehabiltation guidelines.
| ||Aerobic ||Muscle Strength ||Flexibility ||Cognitive ||Education |
|ACSM and ACS ||Overall volume of weekly activity of 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise or an equivalent combination ||Perform 2–3 weekly sessions that include exercises for major muscle groups ||Flexibility guidelines are to stretch major muscle groups and tendons on days that other exercises are performed || || |
Maintain a healthy weight
Regular physician check-ups
|APTA ||Optimize general physical activity for activities of daily living ||Light resistance training ||Range of motion ||Incoporate coordination activities inline with occupational duties and activities of daily living || |
|SGO ||A relaxed pace for 10–15 minutes, and then gradually buidling up more minutes. Ideally, be physically active for at least 30 minutes of moderate activity every day. Maximum health benefits, aim for 60 minutes or more of moderate activity every day, or 30 minutes or more of vigorous activity ||None mentioned ||None mentioned ||None mentioned || |
Maintain a healthy weight
Regular physician Check-ups
The Society of The Society of Gynecologic Oncology (SGO) recently developed recommendations for rehabilitation for cancer survivors to help guide survivorship treatment.15 With similar goals to the APTA, the SGO recommends evidence-based cancer rehabilitation to be a standard of care for survivors. Unfortunately, this is not always the case even though it is widely accepted that exercise and lifestyle changes achieved in rehabilitation will improve survivorship. Specifically, the SGO encourages a healthy lifestyle that engages a healthy diet, stress management, tobacco cessation, and whole system approaches to wellness (see Table 21-1).
The American College of Sports Medicine (ACSM) and the ACS have joint guidelines, which establish detailed exercise prescriptions for cancer survivorship during and after treatment.16 This is the first time where guidelines have been implemented for survivorship just as emphatic as cancer prevention. Our patients need to have a priority of being physically active and eating a healthy diet in survivorship. The ACSM follows 2008 federal Physical Activity Guidelines for Americans, which states at least 150 minutes per week of moderate-intensity aerobic activity.17 Generally, moderate-intensity aerobic exercise, resistance exercise, neurocognitive training, and/or combined programs are the most successful.18 The art and science of exercise prescription in this population should be tailored to each individual’s needs and provide progression using the frequency, intensity, time, and type (FITT) principles of fitness (see Table 21-1).
Overall, the general recommendations of the APTA, ACSM, ACS, and SGO demonstrate that a comprehensive oncology rehabilitation program is a crucial part of recovery for cancer survivors. The balancing act between thriving and surviving should be approached with precaution and a good understanding of contraindications to rehabilitation (Table 21-2). Data from randomized clinical trials indicate that unpleasant symptoms such as fatigue are the largest barrier to exercise and can affect exercise adherence.19 As a result, the APTA, ACSM, ACS, SGO, and National Comprehensive Cancer Network (NCCN) emphasize the importance of oncology rehabilitation on the management of cancer-related fatigue to assist patients in overcoming this barrier.20,21 To that end, the benefits of performing rehabilitation should be considered when contraindications do not exist (Table 21-3). With the mulitdisplnary approach, medically supervised oncology rehabilitation can provide a safe atmosphere for a patient and ensure adherence to lifestyle changes in survivorship.
Table 21-2.Precautions and contraindications to rehabilitation. ||Download (.pdf) Table 21-2. Precautions and contraindications to rehabilitation.
|Anemia ||Exercise may need to be scaled back and possibly avoided |
|Neutropenia ||Exercise should be avoided if there is a fever above 100.4°F (> 38°C) |
|Thrombocytopenia ||Avoid contact sports or activities with high risk of injury or falling |
|Side effects ||Vomiting, diarrhea, swollen ankles, unexplained weight loss/gain, or shortness of breath with low levels of exertion may make exercise unsafe |
Table 21-3.Benefits to rehabilitation. ||Download (.pdf) Table 21-3. Benefits to rehabilitation.
|Weight ||Helps maintain body weight for not only overweight survivors but even those of normal weight |
|Physical functioning ||Maintaining or improving metabolic equivalents can improve morbidity and mortality |
|Cancer recurrence ||Improves overall mortality among multiple cancer-survivor groups, including breast, colorectal, prostate, and ovarian cancers |
|Dietary compliance ||Patients obtain support in dietary interventions to improve compliance to a diet high in fruits, vegetables, whole grains, poultry, and fish |
Lifestyle Approaches to Survivorship Rehabilitation
Today, the majority of research done on rehabilitation programs for oncology patients supports mixed-interventions using strategies to improve body image, aerobic fitness, strength, dietary compliance, weight-loss, stress management, cognitive function, and QOL in concert with reduced fatigue.14,15,16,17,18,19,20,21 However, in gynecologic cancer survivorship, weight-loss and weight management are at the forefront of a successful prognosis, yet endometrial cancer survivors are not likely to modify nutritional intake and exercise without supervision or direct intervention.22 Studies conducted in gynecologic cancer survivors using a broad lifestyle management rehabilitation approach demonstrate reduced stress, which, in turn, decreases stress hormone release and improved weight loss. Studies using the cognitive-behavioral intervention (CBI; eg, relaxation exercises, guided imagery, nature sound recordings) in cancer patients (colorectal, lung, prostate, and gynecologic cancers) had immediate symptom improvements from the beginning of the session to the end of the session.23 Research indicates that elevated levels of stress hormones, such as cortisol and norepinephrine, sustained overtime affect the rate of abdominal fat deposition and the adiponectin-leptin ratio.24 Specifically, Diaz et al24 found that the adiponectin-leptin ratio is significantly linked to disease-specific survival in ovarian cancer patients. Furthermore, in endometrial cancer studies, most women with a larger waist and hip circumferences suffer more than those of normal proportioned survivors.25 When stress hormones are present, weight control appears to be an uphill battle when trying to make lifestyle changes, especially in survivorship. Thus, tackling issues of stress, physical activity, and weight management demonstrates the need for a multidisciplinary approach in oncology rehabilitation.
The National Cancer Institute (NCI) recognizes the need to define patterns of weight, physical activity, and nutrition that contribute to survivorship. From current data, we know the majority of obese cancer survivors are not meeting public health exercise and/or nutrition recommendations. Furthermore, overweight and obese cancer survivors are susceptible to diabetes, coronary heart disease, and premature death.26 Cardiovascular (CVD) comorbidities are the leading cause of death among endometrial cancer survivors. The risk of death from CVD-related causes begins to exceed the risk from cancer-related causes 3.5 years after diagnosis (Figure 21-2).27 Specifically, obesity is the greatest CVD-related risk factor for endometrial cancer. In the prospective study by Ward et al,20 the researchers examined the relationship between cancer, body mass index (BMI), and risk of death, demonstrating a significantly increased risk of death in obese women with endometrial cancer. The relative risk of death for obese endometrial cancer women with a BMI between 30 and 34 kg/m2 was 2.53, and BMI above 40 kg/m2 was 6.25; the highest of all cancers. It is well established that prevalence of obesity is higher in endometrial cancer survivors than of all the US cancers caused by excess body fat. More than 85% of endometrial cancer patients are overweight and approximately 70% are obese—this number is double the percentage of women with breast cancer.28 Conversely, in a large population-based study of 1423 invasive epithelial ovarian cancer survivors, there were no significant associations between height, weight, or BMI and ovarian cancer-specific mortality.29 However, in a cohort study of 1400 women diagnosed with invasive epithelial endometrial cancer prediagnosis, BMI was associated with a higher risk of all-cause 5-year mortality and an increased risk for 10-year CVD mortality.30 Thus, there are mixed data on the relationships of BMI and gynecologic cancer survivorship. Then again, what we do know from a variety of studies is that obesity is related to an overall decline in survival and increases the risk of CVD-death. These authors conclude that obesity is linked to prognosis and overall survival in gynecologic cancer survivors and medically supervised programs to encourage weight loss is essential.
Endometrial cancer cardiovascular death rates following diagnosis. (Reproduced with permission from Ward KK, Shah NR, Saenz CC, McHale MT, Alvarez EA, Plaxe SC.. Cardiovascular disease is the leading cause of death among endometrial cancer patients. Gynecol Oncol. 2012 Aug;126(2):176-9. doi: 10.1016/j.ygyno.2012.04.013. Epub 2012 Apr 13. PMID:22507532.)
Several studies have explored the relationship between BMI and gynecologic malignancies, yet evidence surrounding nutrition and diet still remain inconclusive. Using the Health Eating Index, ovarian cancer patients scored very similar to controls identifying no differences in consumption of whole fruit, dark green and orange vegetables, and whole grains.24 The only significant difference between groups was related to meat and beans, which were slightly higher in controls.31 Thus, a multidisciplinary approach using nutrition and physical activity seems to be the combination for successful survivorship. von Gruenigen et al32 used a whole systems approach in a randomized clinical trial where early stage overweight and obese (BMI ≥ 25 kg/m2) endometrial cancer survivors followed a 6-month lifestyle intervention program supporting physical activity, dietary compliance of fruits/vegetables, and counseling to improve self-efficacy and QOL. The lifestyle program demonstrated significant increases in physical activity, daily intake of fruits/vegetables, and significant weight loss compared with controls in several cohort studies.33,34 Maintaining a healthy lifestyle and routine examinations are also key components to fighting recurrence and improving one’s prognosis. Dietary change and increased exercise together are effective for weight loss and improving CVD risk factors. Several concerns have been raised regarding the safety and efficacy of oncology rehabilitation due to increased oxidative stress generation and free radicals from exercise impairing cellular functions (Figure 21-3).35 However, in a systematic review by Ballard-Barbash et al,36 they identified cancer survivors with higher levels of activity were more likely to reduce risk of death from any cause and there may even be a dose-related response to physical activity. Studies encompassing survivors of breast, colon, prostate, gastric, ovarian, endometrial, and brain cancer report that physical activity is associated with a reduction of all-cause mortality.
Suggested mechanism for the production of free radicals upon reoxygenation of ischemic or hypoxic tissues (Reproduced with permission from Gomes EC, Silva AN, Oliveira MR. Oxidants, Antioxidants, and the Beneficial Roles of Exercise-Induced Production of Reactive Species. Oxid Med Cell Longev. 2012; 2012: 756132. Published online 2012 June 3. doi: 10.1155/2012/756132.)
Exercise is medicine and can provide a protective shield for gynecologic cancer survivors. From a landmark study conducted by Blair and Cooper in 1998,30 morbidity and mortality rates were directly related to physical functioning or metabolic capacity. Most notably, they demonstrated a linear reduction of risk with increasing levels of maximal METs achieved on functional capacity evaluations. Based on these data, the goals of oncology rehabilitation should be to improve patient functional capacity to be between 5 and 8 METs. These moderate-to-high activity levels will double the odds of survival compared with those individuals who have lower maximal MET levels.37 Gynecologic cancer survivors are no exception. In a small study of obese endometrial cancer patients, functional capacity was significantly worse compared with normal obese controls.38 In this instance, regardless of the cancer status, self-reported exercise for both groups was associated with improving health status. This emphasizes the point that peak exercise capacity is a stronger predictor of death than any other risk factors, such as hypertension, diabetes, obesity, heart arrhythmia, high cholesterol, and even smoking.
Oncology rehabilitation does not only provide benefits to maximal oxygen consumption, it also reduces the risk of frailty, especially after cancer treatments. In a study of frail elderly women recovering from gynecologic cancers, BMI was significantly different (P = .02) between groups women who were categorized as not frail (26.1 kg/m2), intermediately frail (31.5 kg/m2), and frail (36.0 kg/m2).39 The risk of frailty is directly related to the excess weight of most gynecologic cancer patients as a result of not meeting public health guidelines for physical activity. The importance for survivors to engage in regular physical activity is plentiful even in various forms of rehabilitation. For example, in a randomized control study of 110 patients, the intervention group performed supervised, home-based training program shortly after chemotherapy. The program included flexibility training, both low- and moderate-intensity exercises over several months after treatment. As a result, the intervention group significantly improved cancer-related fatigue and increased maximal functional capacity compared with the control group.40 Therefore, it is feasible and beneficial for cancer survivors to engage in supervised home-training programs or medically based supervised rehabilitation programs.
Research evidence suggests that individuals with cancer who follow recommended guidelines and observe specific precautions can safely exercise during cancer treatment and in survivorship. However, is there an optimal dose of physical activity to improve survivorship prognosis? Studies show that physical activity and obesity may predict cancer survivorship. There is some evidence suggesting a dose–response effect of increasing risk reduction with increasing physical activity levels.41 In a review by Litterini et al,42 patients are likely to benefit from an oncology rehabilitation exercise program approximately 12 weeks long; however, studies revealed a wide variety of frequency, duration, and intensity of exercise. In these studies, most oncology rehabilitation programs took a multiple mode approach along with a healthy lifestyle education curriculum. Further research is needed to determine the best type, timing, and intensity of exercise for the different types and stages of cancer. Despite these limitations, for the most part, exercise prescriptions have closely followed the published guidelines of the ACSM and ACS joint recommendations. Without reservation, gynecologic cancer survivors should be referred to oncology rehabilitation programs to assist women in making lifestyle changes. It is important to get survivors into supervised exercise and lifestyle programs because most gynecologic cancer survivors do not make spontaneous lifestyle changes. The effectiveness of interventions such as oncology rehabilitation among cancer survivors has demonstrated long-term health benefits and survival.43 In addition, research studies testing the effectiveness of various types of rehabilitation and training regimens for cancer survivors found that exercise was effective in preventing or reducing cancer-related fatigue.44 Thus, physicians have a responsibility to ensure patients get referred to rehabilitation programs to assist a patient’s well being and provide support on the journey of survivorship.
The NCI recognizes that there are few national measures available to accurately measure health-related QOL for cancer survivors.45 The American Association for Cancer Research (AACR) states that obesity can interfere with a survivor’s recovery and subsequent QOL. QOL measures, an example of patient-reported outcomes (PROs), are becoming a common component in patient-centered approaches to survivorship with CIMs, PCMHs, ACOs, and the PCORI. QOL encompasses subjective and objective life conditions as well as personal aspirations and values.46,47 The multiple dimensions of QOL include physical, mental, social, emotional well-being, and development/activity. Within the last 4 decades, QOL has become an important end point relating to the treatment of cancer. Specifically, QOL in endometrial cancer patients are at the forefront of cancer-related QOL due to the early age of diagnosis and number of survivors. Obesity is not only the most significant risk factor for the development of endometrial cancer; obesity also reduces the QOL of endometrial cancer survivors. In a prospective ancillary analysis of women with endometrial cancer, results revealed that increasing BMI correlated with decreasing health-related QOL scores, specifically physical and functional well being.48 Previous work in a meta-analysis from 30 randomized controlled trials in the European Organization for Research and Treatment of Cancer (EORTC) confirmed that QOL could predict survival.49 Thus, QOL measures can provide significant prognostic value of cancer survivors and interventions such as oncology rehabilitation can influence QOL in survivorship.
Recently, a review of the most commonly applied QOL tools for women with ovarian, cervical, endometrial, and vulvar cancers revealed that disease-specific questionnaires are available, but there is little evidence to support the superior sensitivity and responsiveness of cancer-specific versus generic QOL questionnaires.50 Several studies explored this point of QOL symptom-specific and cancer-specific questionnaire to more accurately reflect the QOL domains directly related to survival.49 One study attempted to advance the understanding of QOL in ovarian cancer patients by assessing the top 10 symptoms important to women and their related QOL scores.51 Symptom management, the preservation of functionality, a sense of hope, sleep quality, and the maintenance/improvement of QOL all emerged as important components; however, choosing the right QOL tool is essential to capture the multidimensional experience of ovarian cancer patients stages of their survival. Thus, the specificity of symptoms for each patient should be carefully correlated with an appropriate QOL tool (eg, FACT-O, FACT-G, EORTC QLQ-C30). The psychometric properties of these tools can be beneficial when assessing a woman for QOL concerns, especially after pelvic surgery—meaning that not all QOL tools are created equal. Most notably, a small study of women (n = 50) who underwent pelvic surgery for vulvar, cervical, or endometrial cancer reported significant reduction in sexual frequency, vaginal lubrication, and ability to achieve orgasm; in spite of these results, no differences were noted in QOL/depression between sexual dysfunction groups.52 The results of these studies indicate the importance of engaging women in oncology rehabilitation programs that focus on QOL improvement initiatives specific to each woman guided by a multidisciplinary team of health care professionals. A Cochrane review of 40 trials with 3694 cancer patients revealed positive effects on QOL, specifically body image/self-esteem, emotional well-being, sexuality, sleep disturbance, social functioning, anxiety, fatigue, and pain for those patients participating in a formal intervention program.53 Consequently, interventions facilitating women to improve QOL can greatly benefit women in any stage of treatment for gynecologic cancers.
Often, QOL and self-efficacy are mentioned hand in hand; conversely, they represent 2 separate entities of patient approach to survivorship. Self-efficacy may actually influence the QOL of cancer survivors. Particularly, if a woman feels a sense of confidence toward her survivorship whether it be exercise self-efficacy, weight loss self-efficacy, or self-efficacy toward stressful situations, the more likely she is to have a better prognosis. Limited studies are available to assess the level and type of self-efficacy in women with endometrial, cervical, and ovarian cancers. Principally, because most endometrial and ovarian cancer patients struggle with obesity comorbidities, self-efficacy toward weight loss should be at the forefront of intervention programs. Interventions designed to enhance a woman’s self-efficacy will have a larger impact on her cancer journey. In a randomized intervention study of endometrial cancer survivors by von Gruenigen et al,54 the study demonstrated weight loss and increased exercise correlating to a positive effect on QOL and self-efficacy. The key ingredient in the intervention focused on improving the survivors Weight Efficacy Life-Style (WEL) self-efficacy. An earlier pilot study (n = 45) examining the effects of 6-months of lifestyle interventions on QOL, depression, self-efficacy, and eating behavior change revealed improved self-efficacy and changes in eating behaviors.55 In a randomized control study by Rejeski,56 a positive correlation between weight loss and WEL scores was observed. Patients (n = 288) were randomized to a physical activity only group, a weight loss plus physical activity group, or a successful aging health education program. Those individuals in the combination group of weight loss and physical activity lost 8.6% of their body weight and had significant higher scores for all domains on the WEL questionnaire when compared with the other groups. Mainly, the positive impact of supervised interventions led to increased self-efficacy in the health domains of weight loss, exercise, and nutrition. Ultimately, there is a balancing act that must occur between self-efficacy and QOL (Figure 21-4). The role of the physician after surgical intervention may be foggy to some patients and the even the physician themselves. The follow-up care after reconstruction or treatment typically involves an overview of symptom management postsurgery. Unfortunately, in a review by Lajer et al57, studies showed no evidence of a positive effect on survival in women followed up after primary treatment of endometrial or ovarian cancer. Follow-up after treatment should have a clearly defined and evidence-based purpose. The physician should now take the opportunity to include self-efficacy support and QOL interventions recognizing the important of the psychometric roles of cancer survival.
There must be a balance of quality of life and self-efficacy for treatment to be successful.
Sexuality can include sexual response, sexual roles, and relationships. The World Health Organization defines sexuality as a central aspect of being human throughout life that encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. It is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behavior, practices, roles, and relationships. Not all these dimensions are experienced or expressed at the same time. Each is influenced by the interaction of biologic, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors.58
Historically, sexual health in women has been little researched and poorly understood. A general increase in interest in sex-specific outcomes has led to increased interest in sexual functioning after surgical procedures. To date, our understanding of the impact has been limited by lack of validated tools and retrospective studies. The original, 4-stage description of the human sexual response cycle by Masters and Johnson has since been modified, and represents a linear continuum from desire, through arousal, orgasm, ending with resolution.59 Although this model accurately represents the objective physical changes in sexual function, the full spectrum of psychological components is discounted. Unlike male sexuality, which can in part be objectively measured, in the setting of a mature relationship, female sexuality relies on both physical and psychosocial factors.60 Body image is a component of women’s sexual self-concept related to feeling feminine and attractive, and a high number of sexual problems are associated with impaired body image.
Radical extirpative surgery as a procedure is discussed in its various forms elsewhere in detail. Since initial descriptions of these procedures in the first half of the twentieth century, there have been advances in understanding and technique. When coupled with advances in nonsurgical treatment, as well as perioperative care, morbidity and mortality rates have markedly improved. Indeed, the postoperative mortality rates have been approximately halved over the last 60 years.61 This growing cohort of women postextirpative therapy has led directly to a need for discussion and research in QOL domains, specifically sexual function.
In 1997, Hawighorst-Knapstein et al began reporting on the impact of extirpative therapy on QOL outcomes.62 A prospective cohort of 28 women undergoing pelvic exenteration were interviewed extensively preoperatively (T1), and at 4 (T2) and 12 (T3) months postoperatively using the Cancer Rehabilitation Evaluation System (CARES). In addition, a validated questionnaire developed by Strauss and Appelt60 was used for subject assessment of body image. Significantly, analysis of results was performed based on no ostomy (n = 10), one ostomy (n = 10), or 2 ostomies (n = 8). A separate analysis of women with vaginal reconstruction (n = 11) and without vaginal reconstruction (n = 17) was performed. For patients with 2 ostomies, sexual (P = .039) and marital (P = .027) problems increased significantly from T1 to T2. This group had significantly more problems than patients with 1 ostomy 12 months postoperatively. Compared with the group with no ostomy, the group with 2 diversions had significantly more problems in the sexual (P = .008), and marital (P = .046) domain at T3. When looking at body image, the group with 2 ostomies reported significantly less attractiveness/self-confidence (P = .011) at 12 months than before surgery. In addition, the group with 2 ostomies had significantly higher uncertainty/discomfort compared with patients with no (P = .002) or 1 (P = .028) ostomy at 12 months. Women with colpectomy reported significantly more problems than women with vaginal capacity related to the physical (P = .023) and sexual (P = .010) QOL at T2. These groups also differed significantly in terms of sexual function (P = .015) and marital interaction (P = .017) at 12 months. Women without vaginal reconstruction felt less attractive and self-confident at 4 (P = .046) and 12 months (P = .017) when compared with preoperative states. In a follow-up after 10 years of experience, the same authors presented data on 129 patients and reported similar results.63 In addition, a subset of women who underwent the somewhat less radical Wertheim’s procedure was included in the analysis. Sexual problems were significantly lower for women with a Wertheim’s procedure (T2, P = .010 and T3, P = .032). All patients reported significantly less attractiveness or self-confidence (P = .000) and more sexual uncertainty (P = .001). This effect was exacerbated by adjuvant therapy.
In 2008, da Silva et al56 published prospective data on female sexual function, body image, and self-esteem after colorectal surgery for 93 patients. Significantly, many of these patients underwent surgery for a malignant process, with two-thirds receiving a stoma at the time of the procedure. Using the Female Sexual Function Index (FSFI), EORTC, and sexual function (SF) -36 tools, prospective information was collected preoperatively, and at 6 and 12 months. Sexual function declined significantly at 6 months, with partial recovery at 12 months (P = .02). There was an 8% increase in dyspareunia, with declines in lubrication (9.8%), arousal (8.1%), orgasm (7.9%), libido (4.9%), and sexual satisfaction (4.8%).64 While sexual desire, satisfaction, and dyspareunia improved at 12 months, arousal, lubrication, and orgasm did not. Better sexual function was associated with good body image and self-esteem prior to surgery.
Rezk et al57 confirmed these results among patients undergoing radical procedures for gynecologic malignancy in 2013. In this article, prospective information on the QOL of 16 women was collected preoperatively and at 3, 6, and 12 months after pelvic exenteration. Their results did show a decrease in QOL measures at 3 months, with rebound to near baseline at 12 months (P = .02).65 A similar trend was noted in the sexual function among these patients with a rebound toward baseline seen 12 months postoperatively.
In general, the available prospective data seem to suggest that short-term declines in sexual function are to be expected after extirpative therapy. Fortunately, these declines are reversed to varying degree approximately 12 months after surgery, though it should be noted there is not a full return to baseline. Many patients undergoing extirpative therapy do not have alternative, less invasive options, if cure is the intent. Currently available data suggest part of the counseling process for these procedures should include discussion of the impact on sexual function, with positive emphasis on improvements to near baseline 1 year after treatment.
Pain is frequently inadequately addressed and is a common symptom in cancer patients that can affect both QOL and other systems. In the setting of inadequately controlled pain, analgesics should be given on a schedule rather than when requested or on demand, eg, every 2 to 6 hours. The WHO advocates following a “3-step management ladder.” When possible, there should be prompt oral administration of drugs in the following order: (1) nonopioids (NSAIDs and acetaminophen), then (2), mild opioids as necessary, and then (3), strong opioids until the patient is free from pain. Adjuvant analgesics may also be used, which include those medications with a primary indication other than pain that have analgesics properties. Some adjuvant analgesics are useful in several painful conditions and are described as multipurpose adjuvant analgesics (eg, antidepressants, corticosteroids, alpha-2-adrenergic agonists, neuroleptics), whereas others are specific for neuropathic pain (eg, anticonvulsants, local anesthetics, n-methyl-d-aspartate antagonists), bone pain (eg, bisphosphonates, calcitonin, radiopharmceuticals), musculoskeletal pain (eg, muscle relaxants), or pain from bowel obstruction (eg, octreotide, anticholinergics). Nonpharmaceutical adjuvant therapy can be considered for oncology patients. In a multisite, randomized clinical trial of 400 patients with advanced cancer, both massage and simple touch were shown to improve pain and mood, with massage found to be superior.66
Nausea and vomiting in the gynecologic oncology patient may be disease or treatment related. Nausea associated with slowing of the gut should respond to gastrokinetic antiemetics, such as metoclopramide, that promote gastric emptying and increase gut motility. However, bowel obstruction must be considered in patients with intra-abdominal disease; in these patients, stimulating agents may worsen symptoms. Chemotherapy-induced nausea and vomiting (CINV) is influenced by a number of factors, with the intrinsic emetogenicity being dominant and the factor that most influences antiemetic treatment regimen. Other important factors include sex and age, with female patients and younger patients more affected, as well as dosage. A number of chemotherapy regimens for gynecologic oncology patients include medications of high and moderate risk of emesis, as defined by expert consensus (Table 21-4).67 CINV is classified into 4 subcategories: acute, delayed, breakthrough, and anticipatory. Acute nausea occurs 1 to 2 hours after administration, resolving after 24 hours. Delayed nausea occurs after 24 hours, peaking 48 to 72 after chemotherapy administration, with resolution by day 6 or 7. Anticipatory nausea and vomiting is a conditioned response based on prior experience with chemotherapy. Finally, breakthrough CINV can occur when a patient experiences symptoms despite appropriate treatment. The physiologic pathways that lead to CINV have been elucidated over time, and the central nervous system appears to be the primary site in these afferent and efferent pathways. Treatment of CINV is based on the chemotherapeutic agent with the most emetogenic potential, and the incidence of delayed emesis. First-line agents, classified as having a high therapeutic index, include 3 main classes of drugs: 5-hydroxytrptophan (5-HT3) receptor antagonists, corticosteroids, and neurokinin-1 receptor antagonists (Aprepitant, Fosaprepitant, Merck and Company, Whitehouse Station, New Jersey). Agents of low therapeutic index include metoclopramide, phenothiazines, butyrophenones, and cannabinoids. These can be used for chemotherapeutic agents with low emetogenic potential, or for control of breakthrough nausea and vomiting.68 The incidence of anticipatory emesis is decreasing as adequate treatment of CINV is increasing. When anticipatory CINV does occur, benzodiazepines and behavioral therapy are suggested. A Cochrane review of the literature supports the efficacy of acupuncture point stimulator for acute CINV as well as for postoperative nausea.69 In a randomized study of ovarian cancer patients, all of whom were receiving a standard antiemetic regimen, the combination of vitamin B6 and acupuncture led to significantly fewer emesis episodes and a greater proportion of emesis-free days when compared with acupuncture or vitamin B6 alone. In a randomized, double-blind crossover study in nearly 50 gynecologic cancer patients receiving cisplatin-based chemotherapy, ginger in capsule form was found to be equivalent to metoclopramide for delayed nausea.70
Table 21-4.Emetogic potential of common chemotherapeutic agents by (incidence). ||Download (.pdf) Table 21-4. Emetogic potential of common chemotherapeutic agents by (incidence).
Bowel obstruction in gynecologic oncology patients is a complicated and heterogeneous clinical entity. According to a 2010 Cochrane review, 25% to 50% of ovarian cancer patients will experience a bowel obstruction.71 The causes can be related to benign conditions (eg, surgical adhesions, hernia, or fibrosis after radiation or intra-abdominal chemotherapy), or directly related to the underlying malignancy. Median survival at time of presentation is 4 months.72 Management of bowel obstruction can be medical or surgical and decisions related to bowel obstruction should be based on the prognosis, performance status, and goals of care.
Physiologically, bowel obstruction is the pathologic cycle of distention from gas and nonabsorbed secretions. The resulting damage leads to an inflammatory response and release of vasoactive intestinal peptides, resulting in increase secretions. The patient may present symptomatically with any combination of bloating, pain, cramping, nausea, and vomiting, with severity based on location and degree of obstruction.73 Surgical management may involve bypassing, or resecting, the affected bowel or stenting the stricture. For patients focusing on managing discomfort, a combination of methods can be used, including pain management, antiemetics, corticosteroids, percutaneous gastrostomy placed endoscopically or by interventional radiology, and medications for decreasing intestinal secretions. Octreotide for this purpose has been shown to control emesis and to improve QOL and decrease hospitalization. Care should be taken to evaluate the patient with respect to symptom control, fluid status, and correction of any underlying electrolyte abnormality related to the obstruction. A review of the literature by the Cochrane Collaboration in 2010 found only low-quality evidence comparing medical and surgical treatment of bowel obstruction in ovarian cancer patients. Only one article, Mangili et al,74 was of sufficient quality for inclusion, and was limited by a lack of randomization and QOL measurements. In the article 47 women received either palliative surgery or medical management with octreotide, and overall survival and perioperative morbidity and mortality were reported. Multivariate analysis found that women receiving surgery had significantly better survival when compared with medical management, although 6 (22%) surgical patients had serious complication from the operation, and 3 (11%) died of complications. Women with low performance status were excluded in this group, potentially biasing the result. A recent, prospective report on symptomatology in a small highly selected group of patients with ovarian cancer undergoing palliative endoscopic of operative procedures is available. The researchers noted symptomatic improvement or resolution within 30 days in 23 (88%) or 26 patients, with 1 (4%) postprocedure mortality. At 60 days, 10 (71%) of 14 patients who underwent operative procedures and 6 (50%) of 12 patients who had endoscopic procedures had symptom control. Median survival from the time of the palliative procedure was 191 days for those undergoing an operative procedure and 78 days for those undergoing an endoscopic procedure. For large bowel obstruction, less invasive strategies like colorectal stenting can help patients with recurrent disease. Caceres et al75 have demonstrated the feasibility of this strategy in acutely ill gynecologic cancer patients who had successful stent placement. Like bowel obstruction, constipation is a frequent complaint, and may be related to the disease process, or an adverse effect of pharmacotherapy (ie, 5-HT3 antagonists, narcotics). Constipation that is pharmacologic in nature is best controlled through anticipation, and hydration. Consideration should be given to use of stool softeners, peristaltic agents, and osmotic laxatives. Bulking agents may not be appropriate in patients who are not able to hydrate, have radiation-related dysfunction, or extensive intra-abdominal disease. A presenting complaint may be constipation when the mesenteric plexus is involved with extensive intra-abdominal disease. Treatment is aimed at increasing bowel peristalsis with prokinetic agents (eg, metoclopramide), and avoidance of constipation and impaction with hydration and appropriate laxatives.
Oral and Intestinal Mucositis
Oral and intestinal adverse events can be related to chemotherapy, radiation, or disease progression, presenting as oral and esophageal ulceration, diarrhea, and tenesmus. These morbid side effects are collectively termed alimentary mucositis. The underlying physiologic causes of alimentary mucositis are incompletely understood. However, advances in the understanding of the pathophysiologic basis of mucositis have led to the characterization of oral and gastrointestinal mucositis as a continuum of injury rather than distinct clinical entities.76 Frequently, patients present with mouth and oropharyngeal pain, and impaired swallowing. These complaints can be significant and may require intravenous opioid administration for palliation. When accompanied with mucositis of the gastrointestinal tract, nausea, vomiting, abdominal pain, tenesmus and bleeding may be present. Gynecologic cancer patients with diarrhea and tenesmus need to be evaluated for disease progression. Infection as a causative etiology should be investigated. When infection and disease progression are excluded, pharmacologic intervention (eg, loperamide, octreotide) may improve symptoms of radiation or chemotherapy-induced diarrhea. Tenesmus usually responds to anticholinergic agents, corticosteroids, and opioids, often used in combination. In severe cases of radiation enteritis and proctitis, surgical intervention may be required. This clinical entity is important, and advances in understanding and clinical application ongoing at a rapid pace. Historically, the treatment and interventions aimed at prevention have been variable and largely dependent on local practice. The evidence for these interventions has been varied and often conflicting. In 2011, Cochrane reviewers update their publication on the range of preventative interventions for mucositis, now including 131 studies in their meta-analysis.77 There is evidence of benefit for ice chips (cryotherapy) and keratinocyte growth factor (Palifermin, Amgen, Thousand Oaks, California) for all categories of mucositis, including moderate and severe. It should be noted that Palifermin is approved for hematologic malignancies and patients undergoing stem cell transplantation.78 In the previous recommendations, there was limited and weak evidence for granulocyte-colony stimulating factor, honey, amifostine, intravenous glutamine, and PTA (polymyxin B, tobramycin, amphotericin B) lozenges; this is unchanged. Evidence for low-level laser remains weak; however, benefit was seen in the prevention of severe mucositis.79 Based on expert opinion, a multidisciplinary approach to the care of patients at risk for mucositis may be beneficial. Ongoing preventive and therapeutic oral care should be standardized into the plan of care.
Ascites is a frequent complaint in ovarian cancer patients and can have a significant negative impact on QOL, especially in cases of treatment refractory ascites. Current research points to high concentrations of vascular endothelial growth factor as a cause of ascites due to increased peritoneal permeability.80 Treatment is largely practitioner dependent, though many favor repeated large volume peritoneal paracentesis, which can result in infection. Patient’s QOL is impacted by abdominal distention, anorexia, and pain associated with accumulation of the ascites as well as fatigue, dizziness, and nausea associated with large volume paracentesis, in addition to the physical and emotional morbidity associated with the practice. Diuretics and diet restriction may have a role in treatment of ascites related to portal hypertension, as well as placement of a permanent indwelling catheter. Placement of indwelling intraperitoneal catheters has been studied retrospectively and found to be an effective strategy for palliation of symptoms related to refractory ascites. In 2012, Tapping et al68 reported on retrospective evaluation of 28 patients who had tunneledperitoneal drains placed for the treatment of refractory ascites. Over a 4-year period, 28 patients had tunneled catheters placed, with 5 cases of nonsystemic infection successfully treated with oral antibiotics. Patency was maintained for a mean of 113 days, and the authors report increased patient satisfaction though validated objective measurements were not taken.81 Successful management of refractory ascites using indwelling IP (intraperitoneal) catheters without overwhelming infection has been reported by other researchers, and appears to be an effective and safe means of palliation.82 Case reports have studies showing the successful use of bevacizumab in palliative treatment of ascites in ovarian cancer patients with manageable toxicity profiles.83 New biologic therapeutics may be an option in future treatment of refractory ascites. Further prospective trials should consider evaluation of these agents as a tool for palliation treatment of ascites during the EOL.
Hypercalcemia of malignancy occurs in 10% to 30% of patients with cancer, and etiologies include humoral hypercalcemia of malignancy, which may or may not be mediated by the paraneoplastic secretion of parathyroid hormone-related peptide, and local osteolytic hypercalcemia in the setting of bone metastasis. In gynecologic cancer, hypercalcemia has been reported with ovarian small-cell carcinoma, papillary serous carcinoma, clear cell carcinoma, and dysgerminoma, as well as with uterine leiomyosarcoma and endometrial, cervical, and vulvar carcinomas. A review of more than 5000 gynecologic cancer patients identified 25 patients with hypercalcemia (5%).84 Most patients (82%) had mild hypercalcemia. Severity of hypercalcemia was associated with disease stage, use of hypercalcemia treatment, and survival duration. A review of the published cases in the literature identified 34 patients with humoral hypercalcemia of malignancy that was parathyroid hormone-related peptide mediated, of whom 22 had ovarian cancer, 6 had uterine cancer, 3 had vulvar cancer, and 3 had cervical cancer. Clear cell carcinoma was the predominant histology. Mild hypercalcemia may be asymptomatic, while moderate-to-severe hypercalcemia can be associated with life-threatening neurologic, cardiac, gastrointestinal, and renal events. The treatment of hypercalcemia depends on the level, chronicity, and origin of the condition. General measures to treat hypercalcemia include combining aggressive saline volume replacement and forced dieresis (with loop diuretics), and inhibitors of bone resorption such as bisphosphonates and calcitonin. Glucocorticoids and oral phosphates may also be given, while renal replacement therapy is reserved for severe hypercalcemia with concomitant renal failure. Response is monitored clinically and with serum calcium levels.
Dyspnea is the “subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity,” not necessarily related to hypercapnia or hypoxia.85 Respiratory symptoms, when present, may be related to metastatic disease or from pleural effusion. In addition to baseline comorbidities cancer-related cachexia, malnutrition, fatigue, anemia, and metabolic acidosis may also contribute to dyspnea. When contributing medical morbidities have been optimally treated, interventions should be made based on performance status, prognosis, and goals of care for the patient. In broad categories, interventions may be pharmacologic (eg, opioids, benzodiazepines), physical (eg, thoracentesis, chemical pleurodesis, or placement of indwelling catheter), and emotional (eg, cognitive behavior therapy, breathing training, relaxation exercises). The use of supplemental oxygen was evaluated for relief of dyspnea as indicated in Currow et al,86 where no significant qualitative difference in dyspnea was found with the use of supplemental oxygen. It is important to note, there may be significant safety and cost issues that accompany the presence of oxygen in the home. Absent true hypoxia, the use of supplemental oxygen should be reserved. Nonpharmacologic interventions such as counseling, relaxation, and teaching coping strategies may provide benefit to oncology patients.
Urinary tract symptoms in the gynecologic oncology patient may be disease or treatment related. Women with both early and late stage ovarian cancer may present with urinary urgency and frequency. Cervical cancer patients may have symptoms related to obstruction or extension of tumor into the bladder. Ureteral obstruction may justify mechanical measures including ureteric stent insertion or nephrostomy based on clinical presentation, and consideration of prognosis and goals of care. Treatment-related symptoms include bladder dysfunction after radical hysterectomy, radiation cystitis, or fistula between pelvic structures. Radiation for cervical and endometrial cancer can cause urinary tract symptoms, including immediate effects (bladder irritation or cystitis) and late effects (hematuria, fibrosis, contraction, or fistulas). The increased risk is attributed to disruptions in the uroepithelial barrier secondary to radiation therapy. In cervical cancer, the 10-year bladder complication rate in a series from the MD Anderson Cancer Center was 3%.87 On multivariate analysis, a central pelvic dose of external beam radion higher than 50 Gy, black race, smoking, and obesity were significantly associated with increased bladder complications. In a 2012 Cornell study, among 581 patients with endometrial cancer, treatment with vaginal brachytherapy plus 3-dimensional conformal radiation therapy was associated with higher rates of UTI when compared with vaginal brachytherapy plus intensity modulated radiation therapy, 37.3% versus 9.3%, although both were higher than vaginal brachytherapy alone (2.8%).88 Bladder symptoms may be treated with nonsteroidal anti-inflammatory medications for detrusor irritability or drugs with anticholinergic action to reduce bladder contractility. Infection, and the need for treatment, should also be assessed. Fistulas are ideally treated surgically; however, in the setting of limited prognosis, less invasive options, such as urinary catheterization, may ameliorate symptoms.
Thromboembolic disease, lymphedema, and severe nutritional deficiency can contribute to acute and chronic edema in the gynecologic oncology patient. In addition, recurrent or progressive tumor may contribute to edema. A diagnosis of cancer confers a 4- to 6-fold increase in risk of venous thromboembolism (VTE).89 Age, abdominopelvic surgery, obstructing lesions, and treatment with thrombogenic chemotherapy regimens are additional risk factors for VTE. The risk of VTE remains elevated in the postoperative period, as high as 10 to 50 times higher in the 7 to 12 weeks following surgery, with rates for PE (pulmonary embolism) in ovarian cancer patients as high as 7%. Cancer patients being treated for VTE have a higher risk of recurrence when treated with oral vitamin K antagonists (VKAs). Perioperative prevention of VTE is essential. We support the 2012 recommendations of the American College of Chest Physicians of dual prophylaxis with mechanical and pharmacologic measures, and extended duration pharmacologic prophylaxis (4 weeks) for cancer patients.90 Treatment with a low-molecular-weight heparin is preferred over oral VKAs for patients with VTE.
According to the National Lymphedema Network and the International Consensus Best Practice for the Management of Lymphoedema, lymphedema is an accumulation of lymphatic fluid in the interstitial tissue that causes swelling, most often in one or more limbs, but can occasionally occur in the trunk, breast, genitalia, head, or neck.91 Lymphedema can develop (Table 21-5) when lymphatic vessels are missing or impaired (primary), or when lymph vessels are damaged or lymph nodes removed (secondary).92,93 If lymphatic fluid exceeds the lymphatic transport capacity, then an abnormal amount of protein-rich fluid collects in the tissues of the affected area. Left untreated, this stagnant, protein-rich fluid not only causes tissue channels to increase in size and number, but it also reduces oxygen availability in the transport system, interferes with wound healing, and provides an environment for bacteria that can result in infection. People who develop infections may require numerous hospitalizations and a dependence on antibiotics. Lymphedema can produce physical and psychological issues that may affect mobility and body image. Lymphedema is a chronic condition that is not curable at present, but may be alleviated by appropriate management; if ignored, it can progress and become difficult to manage. It has been reported that 28% to 47% of patients treated for gynecologic cancer develop lymphedema. According to findings from Beesley et al,94 gynecologic lymphedema was more prevalent among vulvar cancer survivors. Cervical cancer survivors who had radiotherapy or who had lymph nodes removed also had higher odds of developing swelling. Uterine and ovarian cancer survivors who had lymph nodes removed or who were overweight or obese had higher odds of developing swelling as well.95 There may be many factors that predispose an individual to developing lymphedema or that predict the progression, severity, and outcome of the condition (Table 21-6). Lymphedema treatment should include components based on the complex decongestive therapy method, which consists of:
Manual lymphatic drainage,
Proper skin care and diet,
Compression garments (sleeves, stockings, devices such as ReidSleeve® Peninsula Medical, Inc. Scotts Valley, CA, CircAid® Medical Products, Inc. San Diego, CA, Tribute Solaris, Freedom to Live, West Allis, WI, as well as other alternative approaches),
Self-manual lymphatic drainage and bandaging, if instruction is available,
Continue to follow prophylactic methods at all times.
Table 21-5.Possible causes of lymphedema. ||Download (.pdf) Table 21-5. Possible causes of lymphedema.
|Unilateral Limb Swelling ||Symmetric Swelling |
|Acute deep venousthrombosis ||Congestive heart failure |
|Post-thrombotic syndrome ||Chronic venous insufficiency |
|Arthritis ||Dependency or stasis edema |
|Baker cyst ||Renal dysfunction |
|Presence or recurrence of carcinoma || |
Drug-induced (eg, calcium channel blockers, steroids, nonsteroidal anti-inflammatory drugs)
Table 21-6.Factors that predispose an individual to developing lymphedema. ||Download (.pdf) Table 21-6. Factors that predispose an individual to developing lymphedema.
|Surgery with inguinal lymph node dissection |
|Recurrent infection in the same site |
|Varicose vein stripping and vein harvesting |
|Intrapelvic or intra-abdominal tumors that involve or compress lymphatic structures |
|Orthopedic surgery |
|Thrombophlebitis and chronic venous insufficiency, particularly post-thrombolytic syndrome |
|Chronic skin disorders and inflammation |
|Unresolved edema |
|Poor nutritional status |
|Concurrent phlebitis, hyperthyroidism, kidney or cardiac disease |
|Advanced cancer |
|Genetic predisposition/family history of chronic edema |
|Postoperative pelvic radiotherapy |
|Prolonged limb dependency |
|Air travel |
|Data from Lymphoedema Framework. Best Practice for the Management of Lymphoedema. International consensus. London: MEP Ltd, 2006. |
As the nation moves from physician-centric care to a patient-centered team approach, our patients deserve more active roles in their survivorship. As health care professionals, we must hear the call of our patients desires to improve survivorship through rehabilitation, QOL, and symptom management. Research evidence suggests that individuals with cancer who follow recommended guidelines during and after treatment may be able to attain the highest quality of survivorship. With new national guidelines putting the patient at the center of communication between oncologists and primary care providers, we need to ensure all survivorship options are available to them.
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