Preparing for the Road Ahead
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By Sue Rochman

Preparing for the Road Ahead

Now living longer than ever, survivors are at risk for delayed and long-term side effects of treatment

By Sue Rochman

To survive cancer often feels like having overcome the impossible, to have looked death in the face and said, “Not yet. Not now.”

It wasn’t that long ago—the 1960s—that more often than not death would win. Consequently, doctors often wouldn’t tell patients that they had cancer, believing the news would be more than they could bear.

Today, of course, that has changed, at least in many parts of the world. The word “cancer” is no longer spoken in a hushed whisper, and doctors want and expect patients to be involved with their cancer care. Most important, cancer survivors are no longer the anomalies they once were, and their ranks continue to grow. There were an estimated 10.8 million cancer survivors in 2004 in the United States alone; and 1.5 million of these women and men had been diagnosed 20 or more years earlier. The average overall five-year survival rate is now about 66 percent for adults and 80 percent for children and adolescents.

These survival statistics reflect advances that have been made in both cancer detection and treatment. But although chemotherapy regimens and radiation techniques have improved, these treatments can still wreak havoc on normal cells, tissues and organs. And this, in turn, can lead to physical, emotional and psychological problems that might not become apparent until 10, 20 or even 30 years after treatment. The attention now being paid to these issues of long-term survivors is reflected in the growing field of cancer survivorship research. And it marks a turning point in cancer care.

Long-Term and Late Effects

Although many cancer survivors experience short- and long-term side effects that begin during treatment, most patients will not live long enough to experience the delayed problems that are commonly referred to as “late effects.” That’s because cancer is primarily a disease of aging, and more than half of all cancer diagnoses occur after the age of 65. As a result, late effects were virtually ignored for years. Over the past 20 years, though, that’s changed, primarily due to the advances in treating cancers that affect children, adolescents and young adults who are living for many decades post-treatment.

Some long-term and late effects are directly related to the type of cancer a survivor had. Others occur across many cancer types because they are the result of the chemotherapy or radiation therapy the patient received. For example, the chemotherapy regimens for many cancers include an alkylating agent, a class of drugs that includes cyclophosphamide (Cytoxan), nitrogen mustard, busulfan (Busulfex or Myleran) and carboplatin (Paraplatin). Late effects of these medicines range from heart and lung problems and an increased risk for secondary cancers to decreased sperm count and premature menopause.

Another widely used class of drugs is the anthracyclines, a category that includes daunorubicin (Cerubidine), doxorubicin (Adriamycin or Rubex) and epirubicin (Ellence). These chemotherapies are effective against many cancers. But multiple studies have shown that the drugs can damage heart muscle, “placing a person at increased risk later in life for cardiomyopathy and congestive heart failure,” explains Sadhna Shankar, a pediatric oncologist who worked until recently at the Monroe Carell Jr. Children’s Hospital at Vanderbilt Medical Center, in Nashville, Tenn.

The long-term and late effects of radiation therapy include second cancers, endocrine system and thyroid problems, heart disease, and infertility or sterility. A person’s likelihood of developing these problems depends upon where the radiation was delivered and the total radiation dosage received. In addition, explains Shankar, who’s now at the pharmaceutical company GlaxoSmithKline, “the damage that radiation can cause is additive on top of any damage you might have from chemotherapy. So if you have both, you are at higher risk of having problems.”

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