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End games, Charles Nesbitt Wilson and cancer survivorship
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The movie Charlie Wilson’s War, based on the book of the same name by George Crile III, depicts the story of Charles Nesbitt Wilson.
Wilson — a former member of the U.S. House of Representatives — was known for leading support for Operation Cyclone, which supplied military equipment to Afghan forces during the Soviet war in Afghanistan.
At the conclusion of the movie, after persuading Congress to provide millions of dollars of support for this effort, he is unable to convince them to provide relatively small ongoing funding to support education in that country.
The film closes with Wilson saying: “They were glorious and they changed the world. ... And then we f---ed up the endgame.”
Although the relationship between this story, the quote and cancer survivorship may seem to be a stretch, there are important messages for us — namely, that management of those affected by cancer is an ongoing continuum of care, not a single episode of treatment; that this care needs to be delivered by a team with solid infrastructure; and that neglecting the longer-term outcomes for cancer survivors risks undoing many of the potential benefits of their treatment with consequent unraveling of their health.
In many respects, we can think about care of cancer survivors as an end game. As with Charlie Wilson’s story, there can be major unintended consequences if we fail to address this stage of the process.
Late consequences
I have discussed survivorship issues in this column before and, as recently as last month, highlighted a new report from the NCI that described the projected increase in cancer survivors and comorbidity burden expected to affect the United States by 2040.
ASCO’s State of Cancer in America: 2016 report — its third annual analysis of trends and developments that influence oncology practice — revealed some sobering data on the frequency of chronic comorbid conditions in patients with cancer. These conditions, of course, will carry through into the survivorship phase of their illness.
In addition, we are beginning to see an increasing number of publications about late effects of cancer treatments.
In the hematologic malignancies world, one could argue this is old news. For many years, we have been aware of the late effects of treatment of children and young adults with leukemia and lymphoma. Many treatment strategies have been developed to minimize the risk for complications, with varying degrees of success. Further, the challenges these patients face go well beyond their physical health and include multiple psychological, cognitive, emotional and social problems, all of which are well documented in the literature.
What is new is the growing body of data about the late consequences for patients who undergo treatment during adulthood and the concern that our treatments are adding to the already substantial comorbidity burden they face.
This edition of HemOnc Today includes coverage of three studies that address this subject.
In a population-based study, researchers used data from Kaiser Permanente Southern California to investigate the risk for cardiovascular disease in a large cohort of cancer survivors. Investigators compared cardiovascular disease risks and outcomes among cancer survivors with controls who had no cancer history.
Results showed an elevated cardiovascular disease risk for survivors of certain types of cancer, including multiple myeloma, lung cancer, breast cancer and non-Hodgkin lymphoma. The cardiovascular disease risk varied by cancer type and, remarkably, was lower in prostate cancer survivors. OS among cancer survivors with cardiovascular disease was significantly shorter than among cancer-free controls.
The second study, again population based, reported on obesity prevalence in adults with a cancer history. This study showed incidence of obesity increased at a higher rate among cancer survivors — particularly survivors of colorectal or breast cancers — than those without cancer. Also concerning is the emergence of another potential racial disparity: The highest risk for obesity in cancer survivors appears to be in non-Hispanic blacks.
The third study explored cognitive function in older survivors of invasive, nonmetastatic breast cancer treated on various protocols, 41% of whom received chemotherapy. This group explored the rate of self-reported change in cognitive function in a large cohort of patients.
Reassuringly, for the most part, these survivors reported good cognitive function. A small subset reported accelerated decline in function, and the risk for being in this group was more than twice as high for those who received chemotherapy combined with hormonal therapy than those who received chemotherapy alone.
‘We must win’
These are all large studies, but they have potential methodologic issues related to their retrospective nature, the methods of data acquisition, the unreliability of ICD-9 coding and so on.
Nevertheless, these reports add to the growing body of literature that tells us we have a major problem to address.
Data from Utah — generally considered among the healthiest states in the United States — show higher rates of smoking among cancer survivors, and that cancer survivors are almost twice as likely as those without cancer to report their activities are limited because of physical, emotional or mental problems caused by their cancer diagnosis.
A study of dietary habits of cancer survivors showed their diets to be less healthy, higher in energy-dense foods, and low in vegetables, grains and many essential micronutrients.
Synthesizing all of these findings into an actionable strategy is a huge challenge. It is clear that many of these effects likely are consequences of now-outdated therapies, and that the pattern of late side effects of treatment will change during the coming years.
It would be naive, however, to expect a major decline in late complications in the foreseeable future, and it is far too early to begin to address the potential late toxicities of the newer targeted agents entering into routine clinical practice.
The care of cancer survivors must remain a high priority, and we should be careful not to allow the amazing progress in treatment to seduce us into a false sense of security about the lifelong management of patients with cancer.
As survival continues to increase, addressing the risks our patients face as survivors — and exploring new approaches to the emerging workforce crisis, to allow us to care for these folks adequately — are urgent priorities.
The (profane) words of Charlie Wilson should be foremost in our minds. We must win this end game.
References:
Armenian SH, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2015.64.0409.
ASCO. J Oncol Pract. 2016;doi:10.1200/JOP.2015.010462.
Bluethmann SM, et al. Cancer Epidemiol Biomarkers Prev. 2016;doi:10.1158/1055-9965.EPI-16.0133.
Greenlee H, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2016.66.4391.
Mandelblatt JS, et al. Cancer. 2016;doi:10.1022/cncr.30208.
Zhang FF, et al. Cancer. 2015;doi:10.1022/cncr.29488.
For more information:
John Sweetenham, MD, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director at Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.