For the sake of the 7.4 million Americans alive today who have a history
of cancer, Ferrell and Hassey Dow's paper is important. Understanding more
about the problems and issues faced by these individuals and their families,
as well as identifying effective ways to ensure that they experience a
high quality of survival, are significant issues for cancer care and research.
Ferrell and Hassey Dow draw on a considerable body of current studies,
a number of which they themselves have conducted, to provide a broad overview
of the challenges that cancer survivors face. A strength of the article
is its clear presentation of the difficulties that cancer survivors experience
in multiple aspects of quality of life (QOL), as identified by studies
of defined groups of survivors and the perspectives of members of the National
Coalition for Cancer Survivorship (NCCS).
Although the article provides an introduction to this subject, it is
less informative about the next steps that researchers and clinicians should
take. Readers would have benefited from the recommendations of such distinguished
scholars. I will identify a number of unanswered questions that occurred
to me as I read this review.
Do Survivors' Needs Change Over Time?--The majority of the research
that the authors review is cross-sectional, providing a snapshot of survivors'
needs at a particular point in time. Although such studies provide an estimate
of the point prevalence of a need, it gives no information about the duration
or varying intensity of a problem. Longitudinal, prospective study designs
with repeated assessments are needed to understand the natural history
of QOL in cancer survivors.
To Whom Should Cancer Survivors Be Compared?--Certain long-term sequelae
can clearly be linked to cancer and/or its therapies. However, some of
the common problems listed by Ferrell and Hassey Dow, such as depression,
are nonspecific. Understanding the significance of such findings requires
one to answer the question, "compared to whom?"
Untangling problems that are unique to cancer and its treatment from
changes due to aging or other chronic diseases is an important challenge.
Studies including comparison groups or normative data from, for example,
individuals matched for age and gender but without a cancer history, would
be very helpful in understanding how cancer survivors are both similar
to and different from other populations.
What About Cancer's Effects on Families?--It is striking that the authors'
study of NCCS members indicates that family concerns cause survivors the
most difficulty, after lingering distress over the initial diagnosis and
treatment. Yet this is one area in which there is very little research,
and, as the authors note, most data are based on the families of breast
We need to learn more about the long-lasting effects of cancer on families.
This focus may be particularly important in the context of the rapidly
developing knowledge about the role of genetics in cancer etiology. As
additional links between genes and cancer are identified, cancer survivors'
siblings and children may experience a new set of concerns about undergoing
genetic testing and the implications of test results on health insurance,
family planning, screening, and other health-related decisions.
Do QOL Concerns Differ Among Survivor Subgroups?--Even after one controls
for disease site and treatment, there may be many other significant individual
factors that affect survivorship. One potentially important consideration
is culture. Virtually no information has been reported on how life quality
may vary among cancer survivors from different ethnic groups. However,
cultural factors may have a profound influence on cancer rehabilitation
and on survivors' well-being.
For example, many Asian and Polynesian cultures stress the harmony among
physical, mental, and spiritual well-being and its role in disease etiology.
Thus, the implications of and problems associated with "recovery"
and "reentry" may differ from the "Anglo" perspective
of cancer as a "disease" that is treated and eradicated.
In addition, in most Asian cultures, the duty of members of one generation
to care for their parents is a strongly held value. In such cultures, cancer
survivors rendered infertile by their disease or therapy may be rejected
as potential marriage partners and occupy a devalued role in that society.
How cultural factors may influence cancer survivorship needs to be elucidated.
What About the Positive Aspects of Being a Cancer Survivor?--Ferrell
and Hassey Dow emphasize the problems associated with surviving cancer.
However, no review of the experience of survivorship is complete without
some mention of the positive sequelae of being a cancer survivor. Cancer
survivors' self-confidence may be enhanced because they have learned that
they can meet and successfully cope with a significant challenge. Many
survivors report that confronting their own mortality helps them to live
more fulfilling lives, as they determine what is important to them and
reorder their priorities accordingly. Although life after cancer may
be different, it may also be better.
Thus, although it is important to learn from the problems of cancer
survivors, it is equally important to learn from their achievements. Future
cancer survivors need to have realistic expectations of the difficulties
they may face, as well as their potential for positive growth.
1. Mullan F, Hoffman B (eds): Charting the Journey--An Almanac of Practical
Resources for Cancer Survivors. Mount Vernon, New York, Consumers Union,
2. Price, R: A Whole New Life. New York, Penguin, 1994.