NCCN Guidelines Insights: Survivorship, Version 1.2016.

The NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for common consequences of cancer and cancer treatment. They are intended to aid health care professionals who work with survivors of adult-onset cancer in the posttreatment period, including those in general oncology, specialty cancer survivor clinics, and primary care practices. Guidance is also provided to help promote physical activity, weight management, and proper immunizations in survivors. This article summarizes the NCCN Survivorship panel's discussions for the 2016 update of the guidelines regarding the management of anxiety, depression, posttraumatic stress disorder-related symptoms, and emotional distress in survivors.

Survivorship: tools for transitioning patients with cancer.

The number of cancer survivors will be increasing over the next decade. Caring for this burgeoning population will place demands on oncologists and primary care providers to meet the needs of the expected large numbers of new patients as the baby-boom generation ages. Many will live beyond 5 years and possibly for decades after diagnosis. Patients experience many transitions depending on the type and stage of cancer, its treatment, and the long-term or late effects they have from the disease and its treatment. The Institute of Medicine's report, "From Cancer Patient to Cancer Survivor: Lost in Transition," recommends that patients be provided with a summary of their cancer treatment and follow-up care plan (ie, survivorship care plan [SCP]), including recommendations on healthy lifestyle behaviors and resources to promote self-care. This plan should be shared with the patient's other health care providers, including the primary care provider. This will facilitate communication among providers and with the patient, which is a key component to quality care. The American College of Surgeons Commission on Cancer has also made providing SCPs to patients at completion of treatment a quality standard. Barriers to providing SCPs have been identified and include lack of time, reimbursement, and knowledge of late treatment effects and current guidelines. Survivorship guidelines are being developed by professional organizations that may be useful for providers. This article provides some practical tools that address these recommendations to help providers and patients with transitions along the cancer trajectory.

Survivorship: screening for cancer and treatment effects, version 2.2014.

The NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for common physical and psychosocial consequences of cancer and cancer treatment. This portion of the guidelines describes recommendations regarding screening for the effects of cancer and its treatment. The panel created a sample screening tool, specifically for use in combination with the NCCN Guidelines for Survivorship, to guide providers to topics that require more in-depth assessment. Effective screening and assessment can help providers deliver necessary and comprehensive survivorship care.

Survivorship: nutrition and weight management, Version 2.2014. Clinical practice guidelines in oncology.

Healthy lifestyle habits have been associated with improved health outcomes and quality of life and, for some cancers, a reduced risk of recurrence and death. The NCCN Guidelines for Survivorship therefore recommend that cancer survivors be encouraged to achieve and maintain a healthy lifestyle, including attention to weight management, physical activity, and dietary habits. This section of the NCCN Guidelines focuses on recommendations regarding nutrition, weight management, and supplement use in survivors. Weight management recommendations are based on the survivor's body mass index and include discussions of nutritional, weight management, and physical activity principles, with referral to community resources, dietitians, and/or weight management programs as needed.

Survivorship: healthy lifestyles, version 2.2014.

Healthy lifestyle habits have been associated with improved health outcomes and quality of life and, for some cancers, a reduced risk of recurrence and death. The NCCN Guidelines for Survivorship therefore recommend that cancer survivors be encouraged to achieve and maintain a healthy lifestyle, with attention to weight management, physical activity, and dietary habits. This section of the NCCN Guidelines focuses on recommendations regarding physical activity in survivors, including assessment for the risk of exercise-induced adverse events, exercise prescriptions, guidance for resistance training, and considerations for specific populations (eg, survivors with lymphedema, ostomies, peripheral neuropathy). In addition, strategies to encourage health behavioral change in survivors are discussed.

Survivorship: immunizations and prevention of infections, version 2.2014.

Cancer survivors are at an elevated risk for infection because of immune suppression associated with prior cancer treatments, and they are at increased risk of complications from vaccine-preventable diseases. This section of the NCCN Guidelines for Survivorship provides recommendations for the prevention of infections in survivors through education, antimicrobial prophylaxis, and the judicious use of vaccines. These guidelines provide information about travel and gardening precautions and safe pet care/avoidance of zoonosis, and include detailed recommendations regarding vaccinations that should be considered and encouraged in cancer and transplant survivors.

Survivorship: cognitive function, version 1.2014.

Cognitive impairment is a common complaint among cancer survivors and may be a consequence of the tumors themselves or direct effects of cancer-related treatment (eg, chemotherapy, endocrine therapy, radiation). For some survivors, symptoms persist over the long term and, when more severe, can impact quality of life and function. This section of the NCCN Guidelines for Survivorship provides assessment, evaluation, and management recommendations for cognitive dysfunction in survivors. Nonpharmacologic interventions (eg, instruction in coping strategies; management of distress, pain, sleep disturbances, and fatigue; occupational therapy) are recommended, with pharmacologic interventions as a last line of therapy in survivors for whom other interventions have been insufficient.

Survivorship: fatigue, version 1.2014.

Many cancer survivors report that fatigue is a disruptive symptom even after treatment ends. Persistent cancer-related fatigue affects quality of life, because individuals become too tired to fully participate in the roles and activities that make life meaningful. Identification and management of fatigue remains an unmet need for many cancer survivors. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and management recommendations for fatigue in survivors. Management includes education and counseling, physical activity, psychosocial interventions, and pharmacologic treatments.

Survivorship: sleep disorders, version 1.2014.

Sleep disorders, including insomnia and excessive sleepiness, affect a significant proportion of patients with cancer and survivors, often in combination with fatigue, anxiety, and depression. Improvements in sleep lead to improvements in fatigue, mood, and quality of life. This section of the NCCN Guidelines for Survivorship provides screening, diagnosis, and management recommendations for sleep disorders in survivors. Management includes combinations of sleep hygiene education, physical activity, psychosocial interventions, and pharmacologic treatments.

Survivorship: pain version 1.2014.

Many posttreatment cancer survivors experience chronic pain, often leading to psychological distress; decreased activity, motivation, and personal interactions; and an overall poor quality of life. This section of the NCCN Guidelines for Survivorship provides screening and management recommendations for pain in survivors. A multidisciplinary approach is recommended, with a combination of pharmacologic treatments, psychosocial and behavioral interventions, physical therapy and exercise, and interventional procedures.

Survivorship: sexual dysfunction (female), version 1.2013.

Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for female sexual problems, including those related to sexual desire, arousal, orgasm, and pain.

Survivorship: sexual dysfunction (male), version 1.2013.

Various anticancer treatments, especially those directed toward the pelvis, can damage blood vessels and reduce circulation of blood to the penis and/or damage the autonomic nervous system, resulting in higher rates of erectile dysfunction in survivors than in the general population. In addition, hormonal therapy can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for male sexual problems, namely erectile dysfunction.

Survivorship: introduction and definition. Clinical practice guidelines in oncology.

Many cancer survivors experience physical and/or psychosocial side effects, which can be severe, debilitating, and sometimes permanent. These NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for common consequences of cancer and cancer treatment for health care professionals who work with survivors of adult-onset cancer in the posttreatment period. These introductory sections of the guidelines include the panel's definition of cancer survivors, a discussion of the effects of cancer and its treatment, general principles and standards for survivorship care, and guidance regarding screening for problems that require further assessment.

Survivorship issues for patients with lung cancer.

BACKGROUND: Survivorship concerns for patients with lung and bronchus cancers include quality of life and physical and psychological aspects. Recommendations for follow-up care should incorporate a survivorship paradigm and practices for these patients. METHODS: The authors conducted a literature review on lung cancer survivorship and the late- and long-term effects of treatment, which can impair quality of life in this patient population. RESULTS: Lung cancer is a diagnosis associated with heavy disease burden, and patients may benefit from survivorship care. High levels of physical and psychological distress leading to diminished quality of life are common in those with lung cancer. Recognition of the potential late- and long-term effects of treatment may help health care professionals intervene early to minimize negative implications. CONCLUSIONS: Survivorship care for patients with cancer requires a multidisciplinary effort and team approach. Addressing the survivorship needs of these patients and their caregivers, along with providing a continuum of cancer care, should improve their quality of life. Further research on evidence-based practices on the long-term effects of lung cancer survivorship care is necessary.

Oxaliplatin-induced peripheral neuropathy's effects on health-related quality of life of colorectal cancer survivors.

Oxaliplatin is a highly neurotoxic chemotherapeutic agent routinely used for the treatment of colorectal cancer. Recent data suggest that oxaliplatin-induced peripheral neuropathy may be long-lasting; however, the effects of persistent neuropathy on colorectal cancer survivors' physical and emotional well-being are not well understood. This cross sectional, descriptive study included persons who had received oxaliplatin-based chemotherapy for treatment of colorectal cancer at Moffitt Cancer Center between 2003 and 2010. Questionnaires including the Chemotherapy-Induced Peripheral Neuropathy Assessment Tool, Center for Epidemiological Studies Depression Scale (CES-D), Insomnia Severity Index, Medical Outcomes Study Short Form 36, and a demographic survey were administered. Pearson's correlations and linear regression analyses were used to examine relationships between neuropathy and depressive symptoms, sleep quality, and health-related quality of life (HRQOL). Eighty-nine percent of participants reported at least one symptom of peripheral neuropathy with a mean of 3.8 (±2.4) neuropathic symptoms. Depressive symptoms on the CES-D were significantly associated with more severe peripheral neuropathy(r = 0.38, p = 0.0001) and interference with activities (r = 0.59, p < 0.0001). Higher degrees of sleep disturbance on the Insomnia Severity Index (ISI) were significantly associated with more severe peripheral neuropathy (r = 0.35, p = 0.0004) and interference with activities(r = 0.52, p < 0.0001). HRQOL was significantly associated with peripheral neuropathy and interference with activities.

Looking beyond recurrence: comorbidities in cancer survivors.

Cancer recurrence is a very real concern for cancer survivors. Surveillance for recurrence and vigilance for development of new cancers are top priorities during follow-up visits after active treatment ends. However, the cancer survivor also is at risk for the development of comorbid conditions. These conditions, including obesity, diabetes, dyslipidemia, menopause, decreased bone mass, hypertension, and hypothyroidism, are discussed with their relevance for general health and their relationships to disease-specific cancers. All of these conditions should be routinely addressed as part of the patient's survivorship care when appropriate. The oncology nurse is in a prime position to educate survivors about the risks for these conditions, both through evidence-based practice guidelines specific to each condition and also through the use of a treatment summary and care plan. This article discusses these selected comorbidities and offers strategies for nurses to address them with survivors during follow-up visits. Clinical practice guidelines for comorbidities are included, along with oncology implications and relevance for survivors. Recommendations for modifiable risk factors and healthy living also are included, along with Web sites for survivorship care plans.

Cancer patients with pain: the spouse/partner relationship and quality of life.

BACKGROUND: A diagnosis of cancer affects not only the patient but also his/her spouse/partner. In addition to facing a life-threatening illness, changes in role and financial threats can impact the dyad. OBJECTIVE: This dyadic study examined the effects of financial concerns and pain on the quality of life (QOL) of cancer patients and their partners. The partner relationship and the partners' coping style were explored for mediating the couples' outcomes. METHODS: Participants consisted of 177 dyads with both sexes as patients and partners in committed, heterosexual relationships. Patients had a mix of cancer diagnoses and were in various phases of treatment. Each participant completed 4 of the same instruments. Partners also completed coping and financial concerns measures, and patients completed pain and symptom distress measures. RESULTS: Pathway analysis, using structural equation modeling, examined the effects of pain and financial concerns on relationship quality, partners' coping style, and QOL for the dyad. Partners' coping style affected only their own QOL (0.16; P = .05). Pain had a significantly negative direct effect (-0.51; P = .05) on patients' QOL and no direct relationship to the partner's QOL. Financial concerns affected the QOL of both patients (-0.13; P = .05) and partners (-0.36; P = .05). The relationship mediated a decrease in patient pain from -0.51 to -0.58, a significant total effect (P = .05). CONCLUSIONS: The partners' relationship lessened pain's negative effect. Financial concerns were a significant issue for both dyad members, but the quality of the relationship was not compromised. IMPLICATIONS FOR PRACTICE: Patients' pain may be affected by the quality of the marital relationship.

Can individuals who are specialists in death, dying, and bereavement contribute to the prevention and/or mitigation of armed conflicts and cycles of violence?

Specialists in death, dying, and bereavement and their consequences for individuals, families, and communities have experience and research findings that are relevant to an understanding of the reactions of individuals faced by deadly violence. At such times, powerful emotions and ingrained patterns of thought and behavior can given rise to disproportionate responses that may feed into cycles of violence. An extended table shows how professionals helping individuals and families faced with violent death share common aims with those aiming to help larger social units faced with armed attacks. It follows that these professionals should work together to improve death education, to prepare people for possible deadly violence and, where possible, to suggest alternatives, to create secure places and relationships in which communication becomes possible, bad news can be broken and understood, feelings examined, differences reconciled, and people can redirect anger into the prevention of escalation rather than its perpetuation. All of these activities hold out hope that cycles of deadly violence can be broken as well as mitigating the consequences when they are not. The undoubted success of the worldwide palliative care movement resulted from the recognition of serious deficiencies in existing services, the provision of an inclusive, holistic, program that extends across medical, social psychological, and spiritual realms of discourse, providing care for patients and their families, irrespective of wealth, race, religion, and political persuasion, by dedicated leaders and teams backed by education and information services and organized across geographical boundaries. It is argued here that the time is ripe for a similar commitment to bring to an end the scandal of armed conflict by a similarly multidisciplinary, multicultural effort to relieve the suffering that both causes and results from armed conflict. This must remain independent of race, religion, political persuasion, and opposing sides and could build upon the leadership, educational models, information services, and international organizations that already exist for the provision of palliative and bereavement care.

Cancer survivorship: history, quality-of-life issues, and the evolving multidisciplinary approach to implementation of cancer survivorship care plans.

PURPOSE/OBJECTIVES: To discuss the history of cancer survivorship, related quality-of-life issues, and cancer survivorship care plans (CSCPs). DATA SOURCES: CINAHL, PubMed, published articles, and Web sites. DATA SYNTHESIS: A cancer survivor is an individual who has been diagnosed with cancer, regardless of when that diagnosis was received, who is still living. Cancer survivorship is complex and involves many aspects of care. Major areas of concern for survivors are recurrence, secondary malignancies, and long-term treatment sequelae that affect quality of life. Four essential components of survivorship care are prevention, surveillance, intervention, and coordination. A CSCP should address the survivor's long-term care, such as type of cancer, treatments received, potential side effects, and recommendations for follow-up. It should include preventive practices, how to maintain health and well-being, information on legal protections regarding employment and health insurance, and psychosocial services in the community. CONCLUSIONS: Survivorship care for patients with cancer requires a multidisciplinary effort and team approach. Enhanced knowledge of long-term complications of survivorship is needed for healthcare providers. Further research on evidence-based practice for cancer survivorship care also is necessary. IMPLICATIONS FOR NURSING: Nurses can review CSCPs with patients, instruct them when to seek treatment, promote recommended surveillance protocols, and encourage behaviors that lead to cancer prevention and promote well-being for cancer survivors.

Considering the patient-partner relationship in cancer care: coping strategies for couples.

A cancer diagnosis, regardless of type or site, raises feelings of fear and loss of control in patients and their partners. Being married is associated with lower mortality from a wide range of illnesses, including cancer.However, the quality of marital interactions is a stronger predictor of health outcomes than marital status alone.When people face great life challenges, they attach importance to their intimate partner's behaviors.Trust, a key component of relationship quality, can lend stability as well as emotional and practical support during treatment.This article will examine the results of research focused on patients with cancer and their partners and discuss the effects of a cancer diagnosis on couples.Recommendations for clinical practice include couple behaviors, communication patterns, and coping strategies.In addition, partners should be included in assessment and interventions to improve the quality of care for patients with cancer.