From Cancer Patient to Cancer Survivor Lost in Transition (2006) / Chapter Skim
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2 Cancer Survivors
2 Cancer Survivors
Pages 23-65
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. Some attention is paid to the definitions developed by the National Coalition for Cancer Survivorship (NCCS)
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. BOX 2-2 The Cancer Control Continuum Prevention Early Detection Diagnosis Treatment Survivorship End-of-Life Care -Tobacco control -Cancer screening -Oncology -Chemotherapy -Long-term follow- -Palliation -Diet -Awareness of consultations -Surgery up/surveillance -Spiritual issues -Physical activity cancer signs and -Tumor staging -Radiation therapy -Late-effects -Hospice -Sun exposure symptoms -Patient counseling -Adjuvant therapy management -Virus exposure and decision -Symptom -Rehabilitation -Alcohol use making management -Coping -Chemoprevention -Psychosocial care -Health promotion The cancer control continuum has been used at least since the mid-1970s to describe the various points from cancer prevention, early detection, diagnosis, treatment, survivorship, and end of life.
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population counts to SEER 9 Limited Duration Prevalence proportions and historical Connecticut Limited Duration Prevalence proportions and adjusted to represent complete prevalence (2004 submission)
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Relative survival is defined as the ratio of the proportion of observed survivors in a cohort of cancer patients to the proportion of expected survivors in a comparable set of cancer-free individuals. The formulation is based on the assumption of independent competing causes of death.
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The National Coalition for Cancer Survivorship (NCCS) , a cancer advocacy group founded in 1986, defined cancer survivorship as "the experience of living with, through, and beyond a diagnosis of cancer" (NCCS, 1996)
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. It describes his personal experience as a cancer survivor.
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While adopting this broad definition, the Office of Cancer Survivorship decided to focus its research on the post-acute diagnosis and treatment phase of cancer care. Cancer Survivorship research encompasses the physical, psychosocial, and economic sequelae of cancer diagnosis and its treatment among both pedi atric and adult survivors of cancer.
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Europeans and others, however, are increasingly viewing survivorship as an important topic for research and health care. CHARACTERISTICS OF CANCER SURVIVORS For statistical purposes, cancer survivors are "prevalent cases"3 and estimates of the number and characteristics of cancer survivors are derived using incidence and survival information from cancer registries overseen by NCI, called the Surveillance, Epidemiology, and End Results (SEER)
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Among male cancer survivors the three leading types of cancer are prostate cancer (41 percent) , colorectal cancer (11 percent)
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population counts to SEER 9 and historical Connecticut Limited Duration Prevalence proportions and adjusted to represent complete prevalence (2004 submission)
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population counts to SEER 9 and historical Connecticut Limited Duration Prevalence proportions and adjusted to represent complete prevalence (2004 submission)
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population counts to SEER 9 and historical Connecticut Limited Duration Prevalence proportions and adjusted to represent complete prevalence (2004 submission)
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populations to SEER 9 and historical Connecticut Limited Duration Prevalence proportions and adjusted to represent complete prevalence (2004 submission)
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, but only 8 percent of the survivor population. Furthermore, among cancer survivors in 2000, African Americans are less likely than whites to be longterm survivors (29 percent versus 38 percent had survived 10 years or more)
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standard population. Hispanics/Latinos are not mutually exclusive from whites, African Americans, Asian/Pacific Islanders, and American Indians/Alaskan Natives.
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. Percent of Census Tract Population Below Poverty Level in 1990 <10% 10%-19.99% 20% or higher 70.0 65.8 64.7 63.4 63.3 60.7 60.8 59.6 (%)
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Information on the health and disability status of cancer survivors is available from the National Health Interview Survey (NHIS)
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. In 1999, 2 percent of individuals with a history of cancer reported cancer as a main cause of disabilities, including ADL/IADLs, functional limitations, and work limitations.
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. Cancer survivors often report having comorbid chronic illnesses, in part because many are elderly (Yates, 2001; Yancik et al., 2001a)
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and NCI co-sponsored the SEER Collaborative Study on Comorbidity and Cancer in the Elderly (Yancik, 1997) .6 As expected, the prevalence and number of chronic comorbid conditions among cancer patients increases with age (Figure 215)
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Prostate and breast cancer patients were least likely to have comorbid conditions, and individuals with urinary system and lung cancer were most likely to have severe comorbid conditions (Figure 2-16)
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What follows are several figures showing, for selected cancers, the 5year relative survival rates at diagnosis, and then the 5-year conditional survival rates at 1, 2, and 3 years following diagnosis. Differences in conditional survival are most pronounced among those with late-stage disease.
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. Information specific to four types of cancer are provided: female breast cancer, prostate cancer, colorectal cancer, and Hodgkin's disease (HD)
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Differential use of these tests has contributed to an underrepresentation of certain groups in the survivorship population, for example, those with poor access to health care. Because there is unequal access to health care in the United States, significant disparities arise in cancer survivorship.
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CANCER SURVIVORS 47 A Colorectal Cancer, Male, All Ages, by Stage 94.2% 94.4% 94.8% 92.6% 85.2% 82.0% 83.4% 79.2% I 72.0% II 65.3% 60.3% III 58.2% Percentage IV 36.3% 23.3% 13.1% 7.1% 5 years Next 5 years, Next 5 years, Next 5 years, from diagnosis from 1 year from 2 years from 3 years after diagnosis after diagnosis after diagnosis Relative Survival B Colorectal Cancer, Female, All Ages, by Stage 91.9% 91.8% 92.7% 91.1% 85.6% 86.7% 83.5% 79.7% 76.3% 69.8% 63.6% I 59.2% II III IV Percentage 39.0% 25.0% 14.5% 7.0% 5 years Next 5 years, Next 5 years, Next 5 years, from diagnosis from 1 year from 2 years from 3 years after diagnosis after diagnosis after diagnosis Relative Survival FIGURE 2-18 Conditional 5-year relative survival rates, colorectal cancer, by sex and stage (modified AJCC staging)
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48 FROM CANCER PATIENT TO CANCER SURVIVOR A Hodgkin's Disease, Male, All Ages, by Stage 91.0% 92.9% 93.9% 89.4% 91.5% 92.1% 90.3% 89.4% 82.8% 86.1% 80.5% 71.5% Percentage Localized Regional Distant 5 years Next 5 years, Next 5 years, Next 5 years, from diagnosis from 1 year from 2 years from 3 years after diagnosis after diagnosis after diagnosis Relative Survival B Hodgkin's Disease, Female, All Ages, by Stage 94.2% 92.0% 92.1% 92.8% 90.5% 90.5% 90.7% 89.8% 86.0% 87.9% 89.6% 76.8% Localized Regional Percentage Distant 5 years Next 5 years, Next 5 years, Next 5 years, from diagnosis from 1 year from 2 years from 3 years after diagnosis after diagnosis after diagnosis Relative Survival FIGURE 2-19 Conditional 5-year relative survival rates, Hodgkin's disease, by sex and age (historical stage)
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200 100 180 90 160 5-year Relative 80 Survival 100,000 140 70 per Incidence 120 60 (%) Rate 100 50 80 40 Survival 60 30 40 20 Incidence/Mortality 20 Mortality 10 0 0 1975 1980 1985 1990 1995 2000 Year of Diagnosis/Death FIGURE 2-20 Trends in breast cancer incidence, mortality, and survival.
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The 20 to 30 percent decrease in mortality associated with mammographic screening (among women aged 50 and older) has also contributed to the growing population of breast cancer survivors, estimated at 2.3 million as of 2002 (NCI, 2005b)
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. TABLE 2-2 Age-Standardized Incidence and Death Ratesa for Breast Cancer (Female)
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This older age distribution of prevalent as compared to incident cases of breast cancer is illustrated in Figure 2-22. With this age distribution, most breast cancer survivors are of retirement age, are likely to be facing other chronic illnesses associated with aging, and are eligible for Medicare health insurance coverage.
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In a population-based sample of 1,800 breast cancer patients diagnosed in 1992, the prevalence of one or more comorbid conditions increased from roughly 15 percent at ages 55 to 59 to more than 40 percent among women aged 85 and older (Figure 2-23) (Yancik et al., 2001b)
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. Between 1988 and 1992, prostate cancer incidence rates increased dramatically; this is probably due to earlier diagnosis through PSA blood testing (Figure 2-24)
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With an estimated 30,350 deaths in 2005, prostate cancer is the second leading cause of cancer death in men (after lung cancer)
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Other research has indicated that men with less than a high school education have much lower survival rates from prostate cancer, even after controlling for stage and 5% 7% 7% 8% 12% Distant 95% 93% 93% 92% Percentage 88% Localized White African Hispanic/ American Indian/ Asian American/ American Latino Alaskan Native Pacific Islander Race/Ethnicity FIGURE 2-25 Stage at prostate cancer diagnosis, by race and ethnicity, U.S., SEER 1996 to 2000.
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. Issues related to the health care provided to survivors of prostate cancer should be of great concern to the Centers for Medicare and Medicaid Services, as four in five prostate cancer survivors are likely Medicare beneficiaries.
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. The higher incidence rates, later stages at diagnosis, and higher mortality rates among certain racial and ethnic group members results in their TABLE 2-4 Age-Standardized Incidence and Death Ratesa for Colorectal Cancer by Race and Ethnicity, U.S., 1997 to 2001 Incidence Mortality Race/Ethnicity Males Females Males Females White 63.1 45.9 24.8 17.1 African American 72.9 56.5 34.3 24.5 Asian/Pacific Islander 56.3 38.6 15.8 10.8 American Indian/ Alaskan Native 38.3 32.7 17.1 11.7 Hispanic/Latinob 49.6 32.5 18.0 11.6 aRates are per 100,000 and age-adjusted to the 2000 U.S.
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Efforts are needed to improve screening for colorectal cancer within these groups. As is the case for other cancer sites, prevalent cases of colorectal cancer are more likely than incident cases to be aged 65 and older (76.7 versus 68.1 percent)
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But for many, an accepted definition of cancer survivors includes all of those who are living with a history of cancer. In this report, the committee decided to focus on the phase of survivorship that follows primary treatment and lasts until cancer recurrence or end of life.
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The probability of long-term survival depends on many factors, including age, type of cancer, stage of illness, and comorbidity, but estimates of "conditional" survival provided to the committee by NCI generally show that cancer patients who have already survived 1 year after diagnosis have a better chance of surviving the next 5 years than the first 5 years after diagnosis. Cancer survivors are likely to have comorbid illnesses, ADL limitations, and functional limitations.
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An examination of the epidemiology of these cancers reveals consistent disparities in incidence, mortality, and survival by race and ethnicity. The sources of the disparities have not been completely explained, but an important reason that African Americans and other members of minority groups are underrepresented among cancer survivors is their relatively poor access to primary health care and effective screening tests and treatments for cancer.
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2005. Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnosis.
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2004. Prostate cancer incidence and survival in relation to education (United States)
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2001b. Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older.
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