Learning Objectives
By the end of this section, you will be able to:
- Define cancer survivor and discuss components of survivorship care
- Describe the physical and emotional impact of cancer recurrence and secondary cancers
- Discuss the role of the health-care team for patients who have experienced cancer in improving their quality of life
- Identify strategies to improve coordination of survivorship care
Survivorship
Cancer treatments, as with all medicine, have changed greatly over the past 300 years. In the 1700s and 1800s, scientists discovered connections between environmental factors, such as chimney soot, and the occurrence of certain cancers, such as squamous cell carcinoma. In the 1800s and 1900s, the use of radiation, tissue-sparing surgical techniques, genetic differences, bone marrow and stem cell transplantation, and medications such as combination chemotherapy, monoclonal antibodies, and hormone therapy expanded cancer treatment options. In the 2000s, the creation of vaccines against known cancer-causing viruses and the introduction of immunotherapy in cancer treatment have improved patient outcomes (McAleer, 2022).
Link to Learning
Read a more detailed timeline of the history of cancer treatments.
Cancer, in general, is now largely considered a chronic condition to be managed, according to the ACS (2024). Disease can be controlled or described as stable. About 18.1 million people in the United States are cancer survivors, and that number is expected to climb to 26 million by 2040 (Tonorezos et al., 2024). Consider, also, that 67 percent of individuals are age 65 or older at the time of diagnosis. The term survivorship embraces the reality of individuals living beyond the cancer diagnosis. Some survivors are completely cancer-free whereas others are living with cancer. Anyone with a history of cancer is considered to be in survivorship (NCI, 2024a).
Link to Learning
This article outlines developing a national standard of care for cancer survivorship with a goal to enhance delivery of survivorship care across the nation.
Challenges for health-care providers include understanding the complexity of chronic management, implementing ongoing surveillance and follow-up care, providing support, ensuring care access, and maintaining good communication with the individual and the care team. To help providers and their patients, there are still many opportunities to enhance availability and quality of health-related services for survivors and to empower individuals to advocate for themselves and use community support services.
Challenges faced by cancer survivors may be psychological, social, emotional, spiritual, or physical. Psychosocial needs include issues with insurance and financial assistance, memory loss, parenting and work guidance, and emotional health. Physical concerns include fatigue, physical functioning, weight changes, chemotherapy-induced peripheral neuropathy, cardiomyopathy, and fertility and sexuality concerns.
Physiological Effects
A delayed effect, or late effect, of cancer treatment is one that arises months or years after diagnosis and treatment. The American Society of Clinical Oncology and the Oncology Nursing Society are among the organizations guiding physicians and nurses in how best to navigate these challenges with patients. These late effects vary somewhat according to the type of cancer, its stage, surgical procedures performed, the chemotherapy medications used, radiation therapy and site, use of hormonal or other systemic therapies, and genetic components.
Psychosocial Effects
The emotional burden of a cancer diagnosis is significant, often accompanied by a pervasive fear of recurrence. The uncertainty and waiting associated with regular diagnostics can exacerbate this fear, leading to heightened levels of anxiety, depression, and trauma-related stress. Patients may experience a sense of helplessness, especially during watchful waiting periods, where they are tasked with monitoring symptoms and alerting their health-care team to any changes. This constant vigilance can be mentally exhausting, adding to the overall psychological strain of the diagnosis.
Cancer diagnosis and treatment can also have profound effects on personal relationships. Familial dynamics may shift as roles and responsibilities within the family unit are redefined. Partners, spouses, and significant others often face unique challenges as they navigate providing support while dealing with their own fears and emotions. Intimate relationships may undergo strain as the focus shifts to managing the physical and emotional demands of the illness, potentially altering the dynamics of the relationship.
Parent-child interactions can be deeply affected by a cancer diagnosis, with parents grappling with feelings of guilt or worrying about the impact of their illness on their children. Children, in turn, may experience fear, confusion, and anxiety about their parent's health and the changes occurring within the family dynamic. Siblings, too, may experience a range of emotions as they navigate their own responses to the family's new reality, from fear and sadness to resentment or guilt.
Maintaining social connections outside of the immediate family can be challenging for individuals with cancer. Friends and acquaintances may struggle to offer support, and unintentionally hurtful comments or actions can lead to feelings of isolation and loneliness. Despite these challenges, many individuals find that their relationships become more meaningful and resilient in the face of adversity. Shared experiences of facing cancer can create bonds of empathy and understanding that strengthen personal relationships and provide much-needed support during a difficult time.
A cancer diagnosis not only affects the individual's physical health but also has far-reaching effects on their emotional well-being and personal relationships. It is essential for health-care providers to address these emotional and relational aspects of cancer care, providing support and resources to help patients and their loved ones cope with the challenges they face.
Sexual Health and Fertility Effects
Fatigue is a significant obstacle to maintaining healthy sexual intimacy. Teaching for the patient and the partner is crucial; this includes setting expectations around thoughts of returning to prediagnosis libido. Shortness of breath may result from physical changes or surgeries, scarring from radiation, or prolonged inactivity during treatment. Other physical changes might include hormonal changes. In women, this can lead to vaginal dryness and discomfort. If radiation or surgery was performed in the pelvic or genital areas, sexual tissues and organs may not respond effectively to arousal. Changes in body image can have a significant mental impact and create possible embarrassment. Depending on the diagnosis, physical changes could include loss of a breast, reconstruction of the labia, or partial removal of the penis, all of which could affect sexual performance and satisfaction. Alternative sexual positions or acts may be a viable solution for the individual or couple involved.
Effective communication is vital for survivors of cervical cancer and their partners as they navigate the impact of the disease and its treatment on their sexual health and intimacy. Survivors should be empowered with language and information to express their feelings and concerns openly. Nurses can facilitate this by providing education on the physical and emotional effects of cervical cancer and its treatment, as well as strategies for communicating about these issues. For example, a nurse may encourage a survivor to use “I” statements to express their feelings and needs, such as saying, “I feel anxious about intimacy” or “I need reassurance and understanding.” This approach can help the survivor communicate their emotions without placing blame on their partner, fostering a supportive and empathetic dialogue.
Additionally, partners of survivors may struggle to express their desires or concerns about sexual intimacy. Nurses can offer guidance on how partners can support their loved ones while also expressing their own needs and feelings. This may include encouraging partners to listen actively, validate their partner’s feelings, and openly share their own emotions and concerns.
Nurses can also emphasize the importance of emotional connection and intimacy in maintaining a healthy sexual relationship. By reinforcing that sexual intimacy is based on more than just physical attraction, nurses can help survivors and their partners prioritize emotional connection and communication in their relationship.
Overall, effective communication can help survivors of cervical cancer and their partners navigate the challenges of sexual intimacy after treatment. Nurses play a crucial role in empowering survivors to communicate their needs and feelings and supporting partners in understanding and responding to these needs.
Life-Stage Context
Effect of Cancer on Females of Childbearing Age
Cervical cancer can significantly affect family planning decisions for women of reproductive age, often requiring an interdisciplinary approach involving nurses. The diagnosis may lead to concerns about fertility preservation and the ability to have children in the future, prompting women to seek guidance from health-care providers, including nurses.
For females yet to complete their family planning, the diagnosis can be distressing. Treatments such as radical hysterectomy, radiation therapy, and chemotherapy can affect fertility, necessitating discussions about fertility preservation options. Nurses play a crucial role in educating patients about these options, coordinating care, and providing emotional support throughout the decision-making process.
The emotional and psychological toll of cervical cancer and its treatment can also strain relationships and affect decision-making about family planning. Nurses, through their ongoing care and support, help patients and their partners navigate these challenges, offering counseling and resources to address the emotional aspects of the diagnosis and treatment.
In some cases, women may choose to delay cancer treatment to pursue fertility preservation options, highlighting the need for a coordinated approach involving nurses, oncologists, and fertility specialists. Nurses help patients weigh the risks and benefits of such decisions, ensuring they receive comprehensive care that considers their fertility goals alongside their cancer treatment needs.
Cancer Recurrence and Secondary Cancers
Cancer is a complex disease that often defies a definitive cure. Instead, treatments aim to achieve remission or control over the disease. Remission signifies a period when cancer is not detectable or actively growing, whereas control involves managing the disease to prevent its progression or symptoms. However, cancer can return after a period of remission, which is known as recurrence. Recurrence indicates that the cancer has resurfaced and is no longer under control or stable.
Secondary cancer can arise in two primary ways. First, factors that contributed to the initial cancer, such as tobacco use, alcohol consumption, or an unhealthy diet and environment, can increase the risk of developing a different type of cancer. Second, cancer survivors may develop a new cancer because of previous cancer treatments. For example, childhood cancer survivors treated with radiation may develop thyroid cancer years later due to radiation-induced cellular damage.
It is important to note that cancer is always named based on its original site of origin. For instance, if small-cell lung cancer spreads to the bone, the malignant bone lesions are still classified as small-cell lung cancer. Despite successful treatment for one type of cancer, individuals can develop a completely different type of cancer. This phenomenon is exemplified by sports analyst Dick Vitale, who faced separate battles with melanoma, lymphoma, and vocal cord cancer, each requiring its own treatment and management (ESPN, 2023).
Additionally, the risk of cancer tends to increase with age, irrespective of an individual’s cancer history. This means that even without a prior cancer diagnosis, the likelihood of developing cancer later in life is higher. Therefore, promoting overall health and well-being remains crucial throughout survivorship to mitigate the risk of developing new cancers or other health complications. The risk of cancer increases as a person ages, regardless of their history, and an unrelated cancer can develop and appear later in life. This is one reason why health promotion continues to be a high priority throughout survivorship.
The Nurse’s Role in Survivorship Care
The primary responsibilities of the nurse in survivorship care are health promotion and symptom management. Ways to improve sleep, nutrition, and activity levels are important to discuss. Cessation of tobacco or alcohol use reduces inflammation and reduces the risk of cancer recurrence. Complementary therapies such as acupuncture, physical therapy, and massage are used by many patients to address symptoms, such as ongoing pain or nausea. In multiple studies, exercise has been demonstrated to be the only intervention that consistently and effectively reduces fatigue and improves overall energy (Campbell et al., 2019; Fabi et al., 2020).
Link to Learning
The National Comprehensive Cancer Network (NCCN) has published the NCCN Guidelines for Patients to provide information that can be shared as part of patient teaching about fatigue management.
It is essential that the nurse reinforces teaching about follow-up appointments, diagnostic testing for surveillance of ongoing remission or recurrence, medication adherence, side effect management, and when to seek medical attention. Additional teaching is often needed regarding manifestations that indicate cancer has recurred or progressed. These teaching points are determined by the type of cancer and subsequent treatments.
Coordination of Survivorship Care
As with active cancer management, survivorship care requires coordination between oncologists, physical therapists, psychologists, or other specialties and services that are involved in a patient’s ongoing care. This can include consultations with dietitians who can assist with appetite loss or protein calorie malnutrition; counseling services to assist with any needs that arise from navigating relationship changes or from psychiatric medication management; and financial assistance programs for people struggling with hospital bills, paying for prescriptions, or returning to work. The nurse may need to refer the patient to support groups or other programs that allow survivors the opportunity to share personal experiences, seek additional information, make connections with others, and develop coping strategies.
Interdisciplinary Plan of Care
Working Together for Cancer Survivors
In the heart of a southern state, a camp designed exclusively for cancer survivors is a beacon of hope and healing. Twice a year, nurses, social workers, and oncology educators unite to create a nurturing environment for adult cancer survivors, including those during treatment. There, participants can openly share their journeys, finding solace in the understanding of others who have walked a similar path.
A nurse’s role extends beyond giving medical assistance to providing emotional support and facilitating therapeutic activities. Survivors discuss the impact of their surgeries on their intimate relationships, sharing vulnerabilities and coping strategies. These interactions are invaluable, offering a safe space for emotional release and healing. Hearing these stories and the advice that helps patients assists the care team members in learning how to better help other patients in the future.
The impact of this camp is not one-sided. Although the focus is on supporting survivors, the camp health-care staff—nurses, social workers, and oncology educators—benefit greatly from this experience. Working in the often-intense environment of inpatient settings, they witness immense suffering and loss. The camp allows them to rejuvenate and to celebrate life with individuals who embody resilience and gratitude. It serves as a reminder of why they chose their professions and a source of inspiration to continue providing compassionate care to those in need.