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Physical Late Effects in Adult Cancer Survivors

Physical Late Effects in Adult Cancer Survivors

ABSTRACT: There are nearly 12 million cancer survivors living in the US today, and these individuals are at risk for long-term physical complications of treatment. Although development of less toxic treatments such as targeted therapies is helping to decrease the risk of physical effects in individual survivors, the absolute burden of physical complications in cancer survivors is increasing owing to growing numbers of cancer survivors combined with demographic and health trends such as population aging. In cancer survivors, direct effects of cancer and treatment exposures converge with pre-existing risk factors such as age, comorbidities, heredity, and lifestyle factors to elevate the risk of physical complications. Oncology nurses have a pivotal role to play in cancer survivorship. This article will provide an overview of physical effects of cancer and its treatment in cancer survivors, identify resources to help guide management, and highlight strategies for integrating cancer survivorship care and education into clinical practice.

Today there are nearly 12 million individuals living in the United States who have ever received a diagnosis of cancer.[1] This number is growing, having just been recently updated to approximately 11.9 million from a previous estimate of about 10.8 million cancer survivors.[2] One half of all men and one in three women will be diagnosed with cancer in their lifetime, with the largest burden being during later life; one in seven Americans 65 years of age and older has a past or present cancer diagnosis.[3]

Despite the traditional definition of a cancer survivor as an individual “from the time of diagnosis, through the balance of his or her life,”[4] cancer survivorship is increasingly recognized as a distinct phase of cancer care that follows primary treatment and is fraught with distinct physical and psychosocial hazards.[3] Consequences of cancer and its treatment present a tremendous challenge to survivors, their families, and their health-care providers. Oncology nurses have a critical role in educating survivors about physical and psychosocial effects and intervening to prevent and minimize their impact on individuals’ lives.

Long-term and late effects are broadly defined as consequences of cancer and its treatment that manifest either during or after cancer treatment and persist beyond the end of treatment.[3] This article focuses on manifold physical late effects, which range from specific sequelae such as radiotherapy-induced cataracts to multisystem consequences of chemotherapy-induced premature menopause, including menopausal symptoms, bone loss, and potential cardiovascular effects.
This article provides a practical approach to late physical effects by focusing on 1) cancer treatment exposures (ie, surgery, chemotherapy, radiotherapy, etc) and 2) their effects on body systems, while considering modifying factors such as age, comorbidity, and cancer diagnosis. Although scant research and guidelines on screening, prevention, and management of late effects remain significant barriers to optimal cancer survivorship care, strategies for integrating the best available evidence into nursing practice are highlighted.


Cardiovascular System

The cardiovascular system provides an exemplar for understanding potential effects by cancer treatment, especially chemotherapy and radiotherapy, which can both lead to cardiovascular late effects. One of the most serious late effects of anthracycline and cisplatin chemotherapy is cardiac toxicity, which typically presents as cardiomyopathy, with clinical signs of congestive heart failure.[5,6] Cumulative dose, administration schedule, concurrent mediastinal irradiation, pre-existing cardiac disease, female gender, and young (< 18 years) or old (> 70 years) age increase risk.[7,8] Cumulative doses of 550 mg/m2 are associated with cardiac toxicity in adults.[9] Patients treated with cisplatin and bleomycin for testicular germ cell tumors are at risk for developing hypertension, increased weight, and an elevated lipid profile.[7,10]

Radiotherapy to a field encompassing the heart, such as mediastinal radiation, confers risk for cardiotoxicity, which is usually delayed and can manifest as pericardial, valvular, myocardial, or coronary heart disease years after treatment.[8] Acceleration of coronary artery disease may also occur, resulting in angina and myocardial infarction. A recent evidence review suggests ways to monitor and treat cardiopulmonary late effects from cancer treatment in adults.[8]


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