Over the last four decades, substantial improvements in treatment effectiveness for childhood and adult cancers have resulted in cure or increased survival for these populations. Over 80% of all patients diagnosed with cancer before the age of 20 years will be surviving at 5 years. As a consequence of both improved survival rates and increasing incidence of childhood cancer, the number of long-term survivors of childhood cancer in the United States is rapidly increasing. An estimated 320,000 or more childhood cancer survivors are living in the United States, and at least 75% of these survivors are now adults. Of these, 24% have survived more than 30 years (1,2). These individuals are living long enough to demonstrate the lifelong consequences of the cancer and treatments (3,4). The numbers of adult cancer survivors are growing as well, with an estimated 18 million adult survivors in the United States by 2022 (Fig. 60-1).
Estimated and projected number of cancer survivors in the United States. Reproduced with permission from de Moor JS, Mariotto AB, Parry C, et al: Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care, Cancer Epidemiol Biomarkers Prev 2013 Apr;22(4):561-570.
In 2006, the Institute of Medicine published From Cancer Patient to Cancer Survivor: Lost in Transition (Hewitt M, Greenfield S, Stovall E. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies; 2006). This seminal report defined the “essential” components of survivorship care as (1) prevention of recurrent and new cancers; (2) surveillance for recurrence, secondary cancers, and medical effects of treatment; (3) intervention for the sequelae of cancer and its treatment; and (4) coordination of care between specialists and primary care providers. Other chapters address disease-specific surveillance; this chapter expands on the first three components of the report.
SCREENING FOR SECONDARY MALIGNANCIES
Patients who have been treated for a cancer are at higher risk for a second primary cancer or recurrence of their primary tumor, most particularly at the time of their transition from active cancer treatment to survivorship. In fact, second- and higher-order cancers accounted for as many as 16% of incident cancers in the SEER (Surveillance, Epidemiology, and End Results Program) database as of 2003 (5). The reasons for this are varied based on malignancy and include factors related to previous therapy (radiation, chemotherapy, hormonal therapies); previous or ongoing exposure to carcinogens; predisposing conditions (tobacco, alcohol, sun exposure, dietary influences, immunologic dysfunction); and familial genetic syndromes, including the BRCA1 and BRCA2 breast cancer syndromes, Bloom’s syndrome, Cowden’s syndrome, Li-Fraumeni, Lynch syndrome, and others (6). The confluence of these factors, which are increased in their incidence in the population of cancer survivors, necessitates a careful approach to screening for second ...