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The growing population of cancer survivors represents a global challenge for survivors and their families, employers, healthcare systems and governments.

The number of cancer survivors is rising worldwide, propelled by advances in early detection and treatment and the aging of the world’s population. In 2018, there were approximately 43.8 million cancer survivors diagnosed within the previous 5 years. (Map 1)

Their growing visibility makes it increasingly clear that while some cancer survivors thrive, for many, life after cancer presents lasting challenges. Fear of recurrence, depression, pain, memory problems, sexual dysfunction, relationship issues and school worries are common. Late effects (occurring months or years after treatment ends) may include cardiac problems, lymphedema, impaired functional status, and second cancers. (Map 2) Combined, long-term and late effects of cancer may double survivors’ risk of poor mental and physical health-related quality of life. (Figure 1)

Many cancer survivors face late and lasting medical, emotional, and social challenges resulting in 7.8 million years lived with disability globally in 2017.

Figure 1. Prevalence (%) of poor health-related quality of life among cancer survivors and adults without cancer, US, 2010.

Poor physical health is experienced by 10% of adults without cancer and 25% of cancer survivors.
Poor mental health is experienced by 6% of adults without cancer and 10% of cancer survivors.
Poor physical and mental health is experienced by 4% of adults without cancer and 7% of cancer survivors.

Working-age cancer survivors often face challenges in maintaining employment. They increasingly experience medical financial hardship, including problems paying medical bills, financial distress, and delaying or forgoing care because of cost. In the USA, as many as 60% of working-age cancer survivors report at least one type of financial hardship.

The challenge in overcoming cancer is not only to find therapies that will prevent or arrest the disease quickly but also to map the middle ground of survivorship and minimize its medical and social hazards.

Fitzhugh Mullan, founding member, National Coalition for Cancer Survivorship

Among older adults, most of those diagnosed with cancer present with one or more co-morbid health conditions. As the proportion of survivors who are older increases, rates of cancer-related morbidity can be expected to rise as well. To reduce the human cost of cancer, finding ways to screen those at risk for and mitigating adverse effects of treatment will be increasingly important, as will tailored follow-up care.

National guidelines for coordinated survivorship care are in place in some high-income countries, such as Australia, Canada, and the UK. (Figure 2) In the US, guidelines are not always consistent. Survivorship care guidelines are less common in low- and middle-income countries. Developing and delivering care that addresses the long-term and late occurring effects of cancer and its treatment represent key challenges of survivorship worldwide.

Figure 2
Suggested site-specific surveillance recommendations for cancer survivors, United Kingdom
Breast cancer (early and local stages)
People who have had treatment for breast cancer should have an agreed, written care plan, which should be recorded by a named healthcare professional.

Offer annual mammography to all people with breast cancer for 5 years.
Colorectal cancer
Offer patients regular surveillance with a minimum of two CTs of the chest, abdomen, and pelvis in the first 3 years and regular serum carcinoembryonic antigen tests (at least every 6 months in the first 3 years).

Offer a surveillance colonoscopy at 1 year after initial treatment. If this investigation is normal consider further colonoscopic follow‑up after 5 years
Lung cancer
Offer all patients an initial specialist follow-up appointment within 6 weeks of completing treatment to discuss ongoing care. Offer regular appointments thereafter, rather than relying on patients requesting appointments when they experience symptoms.

Offer protocol-driven follow-up led by a lung cancer clinical nurse specialist as an option for patients with a life expectancy of more than 3 months.

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Chan RJ, Yates P, Li Q, et al., for the STEP study collaborators. Oncology practitioners’ perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region. BMC Cancer. 2017 Nov 6; 17(1):715.

Fitzmaurice C, Akinyemiju TF, Al Lami FH, et al., for the Global Burden of Disease Cancer Collaboration. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990 to 2016: A systematic analysis for the Global Burden of Disease Study. JAMA Oncol. 2018 Nov 1;4(11):1553–1568.

Hewitt M, Greenfield S, Stovall E (eds.). Committee on Cancer Survivorship: Improving Care and Quality of Life. From Cancer Patient to Cancer Survivor: Lost in Transition. National Cancer Policy Board. Institute of Medicine and National Research Council of the National Academies. Washington, DC: The National Academies Press, 2006.

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Ferlay J, Ervik M, Lam F, et al. Global Cancer Observatory: Cancer Today. Lyon, France: IARC. Available from: https://gco.iarc.fr/today.

Molassiotis A, Yates P, Li Q, et al., for the STEP study collaborators. Mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the Asia-Pacific region: results from the International STEP Study. Ann Oncol. 2017 Oct 1; 28(10):2552–2558.

Rowland JH. Cancer survivorship: new challenge in cancer medicine. In: Bast Jr RC. Croce CM, Hait WN, et al., (eds.). Holland-Frei Cancer Medicine 9th Edition (pp. 909 – 916). Hoboken, New Jersey: Wiley-Blackwell, 2017.

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Zheng Z, Han X, Guy GP Jr, Li C, Banegas MP, Ekwueme DU, Davidoff AJ, Jemal A, Yabroff KR. Medical financial hardship among cancer survivors in the US. Cancer. 2019; Jan 21. doi:10.1002/cncr.31913.

Map 1:
Ferlay J, Ervik M, Lam F, et al. Global Cancer Observatory: Cancer Today. Lyon, France: IARC. Available from: https://gco.iarc.fr/today.

Map 2:
Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, 2018. Available from http://vizhub.healthdata.org/gbd-compare.

Figure 1:
Poor physical health is physical health score < 1 SD below U.S. population mean as assessed using the PROMIS Global Health Scale; Poor mental health is mental health score < 1 SD below U.S. population mean; Poor physical and mental health is physical and mental health-related quality of life < 1 SD below U.S. population mean.

Weaver KE, Forsythe LP, Reeve BB, et al. Mental and Physical Health–Related Quality of Life among U.S. Cancer Survivors: Population Estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev. 2012;21(11):2108.

Figure 2:
Breast: https://www.nice.org.uk/guidance/ng101/chapter/Recommendations#followup
Colorectal: https://www.nice.org.uk/guidance/cg131/chapter/1-Recommendations#ongoing-care-and-support
Lung: https://www.nice.org.uk/guidance/cg121/chapter/1-Guidance#follow-up-and-patient-perspectives