The authors of this article accomplished their goal to provide an overview of physical long-term / late effects. Similar to most available literature published since the Institute of Medicine report in November 2005, it provided a descriptive summary of the epidemiologic data. While vital to increasing the knowledge base of nurses on the frontlines, it provides little guidance as to how to change or improve practice. This is not an indictment of this wonderful article; as the authors mentioned, there is little evidence-based information available.
We all agree that systematic literature reviews, prospective studies, and large randomized trials provide the strongest evidence as to the value of screenings, tests, and treatments. At this point, I must disclose my bias: I am not only a nurse practitioner working in an adult survivorship clinic but I am also the recipient of an allogeneic bone marrow transplant. I do have a vested interest and my concern is the use of evidence-based medicine (EBM) as an excuse to ignore the needs of cancer survivors.
As a provider of care in cancer survivorship, it is discouraging to me that we spend so much time discussing EBM and so little time and effort actually making progress towards this gold standard. In my opinion, the adult cancer survivor population is difficult to study, because of its diversity, the lack of academic interest in outcomes research (publish or perish), and the fact that it would be very expensive to conduct clinical trials that would help us to formulate evidence-based guidelines.
Are these just difficulties to be overcome, or are they indeed barriers that cannot be removed? Oncology researchers are spending a large amount of time and money looking at “drugs” that may improve treatment outcomes by days or months (oftentimes funded by pharmaceutical companies that have a profit incentive behind this research). Don’t we also owe cancer survivors, the victims of our success, the same amount of time and money to examine the late effects of these drugs?
I would encourage anyone interested in cancer survivorship to read “Ethics and Evidence-Based Medicine: Is There a Conflict?” (Med Gen Med 9(3):30, 2007), in which Erich H. Loewy, MD, and coauthors provide excellent resources to assist providers in developing their own standards of practice. I suggest that we must go further, and I would offer this challenge to anyone taking the time to read my musings: Do not sit on the sidelines watching and waiting. Get the important providers in your practice to the table.
Use this article as a starting point to begin discussions on how you can develop a consensus to help standardize the care of the survivors you treat. Perhaps break the assessments down by disease and start with the top 10 combination chemotherapies, radiation fields, and surgeries, then look at what risk each can cause and, based on the literature, what is a reasonable approach towards screening/prevention. Mahatma Gandhi put it best: “You must be the change you wish to see in the world.”
First, “do no harm” is a founding ethical principle used in medicine, and we must ask ourselves whether doing nothing is doing no harm or inaction is causing irrevocable harm. My final thought as a survivor is that I do not want to wait for the evidence to mature before we step forward. If common sense and consensus can improve the quality of life until EBM catches up, then I want the experts’ best thinking now. My life and the lives of many cancer survivors depend on it!
The main article can be found here: