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Addressing the needs of colorectal cancer survivors: current strategies and future directions Expert Rev. Anticancer Ther. 15(6), 639–648 (2015)

Evelyn Yi Ting Wong1, Clarinda Chua2, Sok Yuen Beh2, Dennis Koh3, Dawn Chong2 and Iain Beehuat Tan*2 1 Singapore General Hospital, Singapore, Singapore 2 Department of Medical Oncology, National Cancer Centre, Singapore 169610, Singapore 3 Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore *Author for correspondence: [email protected]

Colorectal cancer (CRC) is one of the three topmost common cancers in men and the second most common cancer in women worldwide. With current advances in the medical and surgical treatment of CRC, care has slowly transformed to curative treatment. With these advances, CRC survivors are increasing in numbers and these patients have a unique range of medical, physical and psychological needs that require regular follow-up. In 2006, the Institute of Medicine recommended that cancer survivors who are completing primary treatment receive a survivorship care plan. There are many different programs of different complexity that are implemented for CRC survivors. This review outlines the needs of CRC survivors, the current surveillance techniques used in the continuing care of patients with CRC after curative treatment and the evidence behind these strategies. KEYWORDS: cancer survivorship . colorectal cancer . exercise . follow-up care . oncology . quality of life

Colorectal cancer (CRC) is the third most common cancer in men (10.0% of the total) and the second in women (9.2% of the total) worldwide. More than 70% of the patients will not have metastatic disease at diagnosis and will undergo surgery with curative intent [1]. Advances in the medical and surgical treatment of CRC have contributed to increased cure rates. Long-term survival is now a possibility for the majority of patients diagnosed with colon cancer [2,3]. After completing curative treatment comprising colectomy with or without adjuvant chemotherapy or radiation, patients may continue to experience complications related to their treatment, are at risk of cancer recurrence and continue to have multiple medical, psychological and physical needs. They are followed up with programs of varying degrees of complexity comprehensiveness and structure. This review outlines the current modalities used in the continuing care of patients with CRC after curative treatment and the evidence supporting these survivorship strategies. What is survivorship care?

The 2005 Institute of Medicine (IOM) report ‘Lost In Transition: From Cancer Patient to

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Cancer Survivor’, identified survivorship care as a distinct phase in the trajectory of care for cancer patients. It outlined four key components of survivorship care: prevention and detection of new cancers; surveillance for cancer recurrence or new cancers and interventions for consequences of cancer and its treatment; psychological distress management; and coordination between specialists and primary care providers (PCPs) to ensure that survivors’ health needs are met [4]. The term ‘supportive care needs’ is an umbrella term, which covers the physical, informational, emotional, practical, social and spiritual needs of an individual with cancer [5]. Specifically, the IOM recommended a comprehensive approach involving a survivorship care plan (SCP) to address these different components of care in a coordinated fashion [6]. The need for survivorship care

Colon cancer survivorship represents a distinct phase of cancer treatment that addresses the long-term concerns of patients. It maintains a smooth transition from a treatment-focused cancer control to one that consists of


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post-treatment surveillance, recovery and rehabilitation, to address the late and long-term impact of cancer [7]. SCPs are meant to be an all rounded, multidisciplinary and multidimensional care. By implementing a structured program for detection and surveillance, it will assist physicians and surgeons in detecting relapsed disease, other noncancer disease progression and treating and managing chronic and late complications of the initial primary treatment. The care plan is also necessary to identify some of the unmet supportive care needs of these survivors, addressing the psychosocial implication of the disease to further augment their transition back to their premorbid state as close as possible [8]. At an institutional level, survivorship care must be improved and developed because of the sheer number of CRC survivors and their unique needs. The overall patient load is high due to multiple follow-up visits that each patient will require to return for. Furthermore, the needs of a CRC survivor are very different from the average patient with cancer on active treatment. This variety of long-term needs require a multidisciplinary team to coordinate and perhaps personalize a treatment care plan for each patient. Finally, because survivorship care is currently still in its early stages, placing resources and research in this new field will definitely open up tremendous opportunities to make an impact in guiding service development beyond individual institutions. Medical needs

The biggest need of CRC survivors still remains that of cancer surveillance. For cancer survivors, one of their greatest concerns is often the persistent risk of recurrence. In addition, they are also at risk for second primary CRCs, with 43% of second primary CRCs occurring more than 2 years after diagnosis [9]. Noncolorectal second primary cancers, such as breast, prostate, genitourinary, skin and lung cancers, are also higher in CRC survivors [10,11]. One of the key reasons for post-treatment surveillance for patients with CRC is to encourage early detection of metastasis. Through early detection, it will encourage the opportunity for curative resection and intervention. Cancer recurrence should be detected before symptom manifestation to encourage better survival rate. Studies have shown that asymptomatic recurrences of CRC may be more amenable to R0 surgical resection [12–14]. For example, in a retrospective review of patients with stage II and III colon cancer, Chau et al. reported that compared with patients who had relapse detected by symptoms, the asymptomatic patients who were detected via imaging of computed tomography had a higher proportion of patients who proceeded to potentially curative resection (26.5 vs 3.1%) [15]. In addition, active surveillance will also detect asymptomatic disease not amenable to curative therapy allowing for early palliative chemotherapy. A study be the Nordic Gastrointestinal Tumor Adjuvant Therapy group have shown that early palliative chemotherapy improve survival and time to disease progression [16]. The American Society of Clinical Oncology (ASCO) guidelines on the follow-up care of CRC recommended that 640

surveillance should be tailored to the risk of recurrence (based on clinical stage and other biological features of each patient cancers) and functional status of the patient. Medical history, physical examination and carcinoembryonic antigen testing should be performed every 3–6 months for 5 years. In terms of imaging, a CT scan (abdominal and chest) is recommended annually for 3 years, in most cases. A surveillance colonoscopy should be performed 1 year after the initial surgery and then every 3–5 years, dictated by the findings of the previous endoscopy. They also recommend that if a patient is not a candidate for surgery or systemic therapy because of severe comorbid conditions, surveillance tests should not be performed. Surveillance is vital for identification of recurrence and patient survival. Although guidelines have been established regarding the follow-up periods and the follow-up modalities, the optimal delivery of cancer surveillance for these survivors has yet to be optimized. The aim should be to coordinate investigations and to encourage compliance as they undergo transition from active treatment to survivorship (i.e., or who should be responsible for providing that care). Although guidelines have been established, a previous study conducted by Lafata et al. [17] found that only approximately 75% of CRC survivors had two surveillance visits within 18 months. The guidelines described focus on surveillance for cancer recurrence. They neither address the cancer survivors’ needs for primary and preventive care nor do they specifically address what physician specialty survivors should see for their surveillance. In addition to surveillance for cancer recurrence, physicians need to address other medical comorbidities and also use opportunities for preventive medicine. The burden of comorbidity is high with 80% of CRC survivors having at least one comorbidity [18,19]. These common comorbidities include cardiovascular disease, musculoskeletal conditions and psychological conditions. The combination of a cancer diagnosis and comorbidity will, in turn, translate to a lower health-related quality of life, lower productivity and more health and functional limitations, even in survivors of more than 5 years cancer free [20]. Earle and Neville [21] compared 5-year CRC survivors to matched noncancer controls to examine patterns of care and found that cancer survivors were less likely to receive recommended care for chronic conditions. Cancer survivors monitored by both oncology specialists and PCPs were more likely to receive appropriate care, with PCPs more likely to provide noncancerrelated recommended care and oncology specialists more likely to provide cancer-related recommended care. A study of breast cancer survivors produced similar findings [22]. Snyder et al. [23] studied 1541 patients with stage 1–3 CRC. The article explored the mix of physician specialties that these long-term colorectal survivors visit, and how these mix relates to preventive care. It is noteworthy that cancer screening decreases as oncology specialists become less involved in cancer survivors’ care. That survivors who saw both a PCP and oncology specialist were most likely to receive influenza vaccination, mammography and cervical cancer screening, whereas patients Expert Rev. Anticancer Ther. 15(6), (2015)

Addressing the needs of colorectal cancer survivors: current strategies and future directions

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who saw a PCP only were most likely to have cholesterol screening and bone densitometry suggests a possible division of labor between oncology specialists and PCPs. As oncology specialists become less involved in survivors’ care, the system may fail to identify the need to transfer responsibility for these preventive services to the PCP. CRC survivors have been given detailed guidelines about the frequency and intensity of follow-up. However, there are still many gaps in the SCP, such as who should follow-up with the patients and their screening for noncancer-related medical comorbidities. Physical activity in colorectal cancer survivors

Cancer survivors spend upward of 70% of their day in sedentary behavior [24], where sedentary behaviors was defined in an article as ‘waking activities performed in a seated or reclining posture that require very low energy expenditure’ [25]. A consistent and growing body of literature indicates regular and sustained moderate-vigorous physical activity is associated with health-related quality of life and reduced fatigue symptoms among CRC survivors [26–28]. Mosher et al. reported that while many cancer survivors are interested in lifestyle modification, there is a high prevalence of suboptimal health behaviors [29]. The study that involved a total of 753 older long-term breast, prostate and CRC survivors also identified some risk factors for suboptimal health behaviors. Older age, less education and greater comorbidities were associated with reduced physical functioning and greater role limitations due to physical problems. Data also suggest that exercise may reduce the risk of cancer recurrence and mortality among colorectal and breast cancer survivors [30–32]. Convincing evidence of a preventive effect exists for colon cancer, where meta-analyses of over 60 studies suggest a reduction of 20–25% in colon cancer risk in people with the highest level compared with people with the lowest level of physical activity. The source of physical activity does not matter as occupational and leisure-time activities confer similar reductions in risk, and a dose-response effect exists [33,34]. Other studies in European and Asian populations found similar associations [35–39]. Despite these convincing data, public awareness of the role of physical activity in the prevention of colon cancer is low [40]. There is currently a study called the CHALLENGE study, led by the NCIC Clinical Trials Group in Canada, to test whether exercise can improve survival in patients with cancer [41]. Putting the case of malignancy aside, in general, physical activity lowers the risk of premature death, cardiovascular disease, diabetes, falls and metabolic syndrome; improves cardiopulmonary fitness, cognitive function in older adults, sleep quality and bone density and contributes to weight loss and weight maintenance when combined with calorie restriction [42]. These are all important factors in managing the comorbidities of CRC survivors. A meta-analysis of physical activity intervention trials in various cancer survivor populations concluded that physical activity was safe during and after cancer treatment [43]. Physical activity has shown to be potentially beneficial in preventing recurrence of CRC and the comorbidities that informahealthcare.com

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patients with cancer will face. More research should be done into the minimum intensity and duration that patients with CRC should be encouraged to partake in. In addition, public awareness of the role of physical activity in the prevention of CRC has been identified to be low. Future research can be done to evaluate the best way to increase public awareness and patient participation in exercise. Behavioral seeking needs of colorectal cancer survivors

When confronted with a potentially life-threatening illness, such as cancer, the patients and survivors likewise will want information with regards to their disease, the treatment that they have undergone, its side effects, the risk of recurrence and other self-care management. Mayer et al. [44] reported a study that examined 619 cancer survivors and the different factors that encourage information-seeking behavior. They found that close to two out of three of survivors sought cancer information and although most survivors prefer receiving cancer information from their regular healthcare provider. The study had shown that information seeking also facilitates coping by mediating uncertainty and anxiety and by providing social support. There have been many other behavioral seeking studies that documented the now prevailing paradigm: the majority of cancer survivors desire as much information as possible about their disease and treatment [45–47]. However, not all survivors would want that much information. The amount and timing of information desired varied in those with a blunting style (avoiding threatening information) or for those trying to maintain hope [48–53]. The benefits of information for patients with cancer have been studied in particularly in the patients with breast cancer. Although research is minimal in patients with CRC and the benefits of having sufficient information, nonetheless the benefits of information seeking behavior should still be recognized. These benefits include more patient involvement in decision making, translating to greater satisfaction with treatment choices [54]; improved coping mechanisms during the diagnosis, treatment and post-treatment phases [55–57]; reductions in anxiety and mood disturbances [58,59] and improved communication with family members [60–62]. Salz et al. [63] studied the needs and preferences of CRC survivors for survivorship information. In the study, it was noted that among those who did not receive any survivorship plan, knowledge of the most salient aspects of diagnosis and treatment was generally accurate. Taken together, survivors in the study generally recalled basic information about their diagnosis and treatment, although they recalled less information about their stage and ongoing risks. Also, respondents more frequently reported receiving medical information about their cancer or its follow-up than about nonmedical issues, such as support groups, counseling and financial and insurance issues. The lack of communication about nonmedical issues, ranging from psychosocial support to practical problems, highlights the need for multidisciplinary support for cancer survivors. 641

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psychological and social functioning [71]. Most reports of survivor QoL have shown that mental and physical QoL was EORTC QLQ-C30 EORTC QLQ-CR38 FACT-C poorer for these survivors of different Physical well-being Functional scales: Functional scales: cancer than for age-matched individuals Social/Family well-being Body image Physical function without cancer [72]. The most prevalent Emotional well-being Future perspective Role function concerns reported 1 year after diagnosis Functional well-being Sexual functioning Emotional function and treatment were fear of recurrence Colorectal Cancer Specific Sexual enjoyment Cognitive function (68%), fatigue (67%) and sleep difficulFACT-C Total score Symptoms scales: Social function ties (48%) [73]. Although elderly longTrial Outcome Index Radiation-induced Global QoL/GHS Colorectal effects micturition Symptoms scales: term survivors generally reported low Chemotherapy side effects Fatigue levels of anxiety and depression overall, General gastrointestinal symptoms Pain they had worse psychological outcomes Defecation problems Nausea and vomiting and used more mental health services Stoma-related problems Single items: than individuals without cancer [74–76]. Sexual dysfunction of men Dyspnea This is an issue for CRC survivors, as the Sexual dysfunction of women Sleep disturbance age-adjusted rate of CRC for individuals Weight loss Appetite loss Diarrhea over 65 years of age is more than threeConstipation times higher than for persons aged Financial impact 50–64 years. EORTC: European Organisation for Research and Treatment of Cancer; FACT-C: Functional assessment of With regard to emotional status, cancer therapy- colorectal cancer; GHS: Global health status; QoL: Quality of life. depressive symptoms (measured by the CES-Depression Scale) of CRC survivors Emotional needs & quality of life were not especially high at diagnosis and improved over the Although CRC survivors generally report an excellent quality course of the first year after treatment [54]. Survivors without of life (QoL), a cancer diagnosis can negatively affect functional limitations of their daily social activities, with better social netand social wellbeing [64,65]. Consequences of the cancer and works as well as community involvement, had better mental treatment, such as fatigue, physical discomfort, negative body health outcomes [54,77,78]. Despite low levels of depressive sympimage, depression and physical limitations, may persist for years toms, 26–44% of long-term CRC survivors continued to worry after diagnosis. These are particularly so in patients who receive about cancer recurrence, symptoms as cancer indicators, getting radiation therapy, surgery involving a stoma, in elderly or a second malignancy or future diagnostic tests. Cancer-related female survivors, or in overweight, obese or low-income survi- health worries were associated with anxiety and depression, with vors [66,67]. In the study by Schneider et al. [67], it was noted 24% of the survivors reporting depression scores that were high that patients who received a diverting ostomy were more likely enough to need evaluation for clinical depression [79]. Thus, than others to report negative feelings of their physical image. screening for psychological distress, depression, fatigue and pain In the study by Rauch et al. [66], it was noted that physical is warranted in all CRC survivors and may identify issues requirfunctioning was reduced with age, residual pain, stoma and ing intervention to improve their QoL after treatment [80]. comorbidity according to the QoL QLQ-C30 survey questionIn addition, in CRC survivors, there is always a possibility naires. The study also noted that women tended to have a of living with the long-term complications of having a stoma higher chance of depression. creation after surgery. The presence of a permanent stoma may There are many different scales that are currently being used affect QoL. Survivors with a permanent stoma who had been with the more frequent ones are the European Organization for treated with radiotherapy followed by surgery for locally Research and Treatment of Cancer QoL QLQ-C30 [29], vali- advanced rectal cancer reported improved bowel symptoms, dated in all European languages, the colorectal module QLQ- fatigue and pain compared with pretreatment levels [81]. HowCR38 [68], and the Functional Assessment of Cancer Therapy- ever, the presence of a stoma has also been associated with General version FACT-G [69], or named FACT-C [70] when diminished body image and increased financial worries specific concerns of patients with CRC are added to common although global QoL was not affected [82,83]. items to all patients with cancer (TABLE 1). Although overall QoL Mullens et al. [78] found that in CRC survivors, there is a is high, however, due to cancer- and comorbidity-related issues, significant, although modest, relationship between perceived research and help in their QoL is still vital. These interventions risk and worry and intentions to make health-related behavior should complement the impact of a cancer diagnosis with chances. Although it is true that we should be concerned about regards to the QoL and the survival outcomes. the emotional needs of CRC survivors, however, should there QoL, the subjective evaluation of one’s personal satisfaction be a minimal level of worry and perhaps dealt with properly by with overall health and well-being, is an important outcome of a physician, this worry may be productive in motivating indicancer survivorship that include physical, functional, vidual to engage in healthier lifestyle.

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Table 1. Comparison of the different QoL scales in particularly for colorectal cancer EORTC QLQ-C30, EORTC QLQ-CR38, FACT-C.

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Treatment-related complications

CRC survivors will have to deal with the long-term complications of their treatments as well. There are many complications and side effects that are related to their treatment as well the surgery that they will have to go through. As a side effect of chemotherapy, some of the patients will have oxaliplatininduced peripheral neuropathy. Nonsteroidal anti-inflammatory medications, opioids and referral to neurology or pain management for persistent symptoms are encouraged although their efficacy is unknown [84]. Another common side effect would be that of bowel dysfunction. Chronic diarrhea is reported by 13–50% of patients up to 10 years after treatment. Diarrhea has been associated with limitations in activity and can negatively affect QoL [67,85]. Treatment for bowel problems after treatment for CRC typically includes antidiarrheal medications, bulk-forming agents, use of pads and diet manipulation [86]. Elimination of specific foods (fats and oils, meat, milk products, raw vegetables or fibrous foods) and the use of probiotic supplements has had limited benefit [87,88]. Physicians can make an effort to regularly ask patients about their bowel habits. Patients may assume that abnormal bowel symptoms are inevitable consequence of their treatment. They may not raise these problems in their followup appointments unless they are regularly asked [89]. Lifestyle & diet

Cancer survivors very commonly ask about the role of diet, nutritional supplements in preventing recurrence. One of the more commonly phrased questions is regarding the type of dietary habits they should keep. In a prospective observational study of dietary patterns in 1009 colon cancer survivors who received adjuvant chemotherapy, higher intake of a Western diet pattern (high in meat, fat, refined grains and dessert) was associated with a more than three-fold decrease in disease-free survival compared with those with the lowest intake of the same diet, with a similar decrease in relapse-free and overall survival. However, no association was found between a prudent diet and disease recurrence [90]. Additional studies are needed to delineate which components of such a diet show the strongest association. In addition, some patients have also enquired about the use of supplements to prevent recurrence. Some prospective cohort studies have shown lower overall and CRC-specific mortality with consistent aspirin use and high circulating levels of 25-hydroxyvitamin D. Previous research studies have shown that large doses of aspirin can decrease the incidence of colon polyps. Aspirin use may also prevent precancerous lesions. In this recent study, researchers took 830 patients with stage III colon cancer of which 8.7% were regular aspirin users. Extensive analysis revealed that 72 of the 830 patients consistently used aspirin during and after treatment. A comparison of this group with nonaspirin users determined that consistent aspirin use was associated with a significant reduction (48%) in the risk of disease recurrence and death [91]. Studies have also shown evidence of an inverse association between vitamin D intake, 25-hydroxyvitamin D status and informahealthcare.com

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CRC risk [92]. In a recent meta-analyses study, it was observed to have inverse associations of CRC risk with dietary vitamin D in 10 known studies and serum/plasma 25-hydroxyvitamin D in six studies. Supplemental and total vitamin D intake and 25-hydroxyvitamin D status were inversely associated with colon cancer risk [93]. Improving vitamin D status could be potentially beneficial against CRC incidence. Although this association is still debatable, the role of physicians in encouraging their patients to have vitamin D supplementation can be explored. Lifetime tobacco usage may also impact colon cancer recurrence, with trends toward lower disease free survival in survivors with a 20 pack-year or greater smoking history compared with never smokers [94]. These studies provide hypotheses for further prospective investigation and possible interventions to improve outcomes in CRC survivors. However, this association requires further investigation, and in addition, smoking is a well-known risk for other types of cancers such as lung cancer and should not be encouraged. The role of a physician should be to encourage their patients on maintaining a healthy lifestyle and diet not just to prevent recurrence of their cancer but to manage their comorbidities as well. The need for a survivorship plan in view of the patient’s needs

Having previously described CRC patients’ needs within the individual domains and the ability to intervene for these domains, this section describes how to coordinate all the domains into a plan and how institutions can organize these plans. A shared model of care is ideal for survivorship care and has been suggested to be facilitated by a SCP. To address these supportive needs, IOM recommended that all patients receive treatment summaries and SCP [4,95]. The SCP comprises a summative, synthesized cancer care record including treatment summary with diagnosis, stage, primary treatments and toxicities or side effects and is often accompanied by oncology provider recommendations for surveillance testing, identifying health priorities related to both cancer therapy and general health, as well as more importantly, it indicates how and by whom and in what setting, should follow-up care be provided for each of the domain and issues identified. In the article Cancer Survivorship – Challenges and Changing Paradigms [96], the author SM Gilbert outlines four commonly applied models for cancer survivorship in the area of urological cancer: 1. Shared care model that involves a coordinated and cooperative care between two or more healthcare providers in different specialties. For example, one study reported that colorectal cancer survivors managed by both an oncologist and a primary care physician were significantly more likely to receive recommended care compared with those managed by either one alone [21]. 2. Risk-based follow-up care: risk-based approach has been used to address differential surveillance requirements based 643

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on severity of disease, treatment characteristics and risk of detrimental health effects and provide an appropriate level of care at the individual level. A principal component of the risk-based approach is that it can be tailored to the specific needs of each cancer survivor. 3. Cancer-specific survivorship: care is generally coordinated by an oncology nurse practitioner, a multidisciplinary approach consisting of surgical, medical and radiation oncologists, as well as reconstructive surgeons is generally used. Diseasespecific cancer survivorship programs were first initiated in breast cancer to address treatment-related effects, such as lymphedema, changes in body image, depression, weight control and less commonly, cardiac disease. 4. Institution-based survivorship: in contrast to disease-specific survivorship clinics, these programs, which are institution based, are directed toward providing coordinated and tailored care to survivors of all cancers in a single clinical setting. In theory, it limits the redundancy inherent in operating several cancer-specific clinics. Latest trends in individualized care

Molecular pathological epidemiology is known as the epidemiology of molecular pathology and heterogeneity of disease [97]. Through these studies, we are able to understand better the relationship between: environment, lifestyle and habits, genetic mutations and tumor progression. These studies will not only show more precise interrelationships between tumor burden and environment factors but also give insight into the pathogenesis, linking the differences in genetics with the molecular signature of the tumor. These factors may contribute to the individualized care and interventions for CRC survivors. The concept of personalized medicine with rationally designed or selected drugs tailored to the molecular pathology of the tumor (e.g., Herceptin for HER2+ tumors) [98] could also have a role in survivorship care. A case in point would be the study by Liao et al. [99] that showed that regular use of aspirin in patients with CRC with the PIK3CA mutation in their tumor genetics was associated with longer survival. This way, the PIK3CA mutation would then serve as a predictive biomarker for the initiation of adjuvant aspirin therapy. The need for long-term aspirin therapy, perhaps in selected patients, will add another dimension to coordination and delivery of survivorship care in CRC. Survivorship care in colorectal cancer

Since the IOM report, many organizations have created SCPs and survivorship resources such as the ASCO, National Comprehensive Cancer Network, American Cancer Society, National Cancer Institute, LIVESTRONG, and Center for Disease Control, Oncology Nursing Society, and National Coalition for Cancer Survivorship, and WellPoint/Journey Forward. An exploratory study by Leigh Anne Faul et al. in 2012 [100] looked at the different survivorship care planning in patients with CRC. They used in-depth individual semistructure interviews, asking CRC survivors their preferences for a SCP. The 644

plan that they used was modeled after templates that were developed by the ASCO. In the study itself, it was noted that the SCP had allowed the survivors to have a detailed and wellplanned summary of their treatment and a ‘roadmap’ for what they could expect in terms of follow-up care. Despite the small sample size, majority of them had shared their plan with other doctors outside the centers for their own general medicine follow-up care. Close to all of them also found it useful to discuss the psychological impact of their worry and fears regarding cancer recurrence. According to the study, the survivors had commented that the SCPs had brought them ‘peace of mind’ through the facilitation of survivors efforts to reduce cancer worry via coping and obtaining surveillance to monitor for potential recurrence and to suggest physical changes that they can do with their lifestyle to promote more health living. In this article, all of the oncology providers that they interviewed noted that these care plans will have the capability of augmenting both continuity and quality of cancer care. However, their concerns were mainly around the implementation of these SCPs. Some of the issues the article raised were to would be that of time investiture and the long-term sustainability of these care plans, the issue of electronic versus paper records, as well as the capability of the forms to be easily updated over time. Expert commentary

The IOM 2006’s landmark report From Cancer Patient to Cancer Survivor: Lost in Transition (Hewitt et al., 2006) [4] identified a lot of long-term challenges, unmet needs and gaps in the care that CRC survivors face. These issues include the late effects of cancer treatment, lifelong emotional effects and tumor recurrence. The report also talks about numerous service provider issues, such as that of poor coordination of care, lack of communication between patient and patient care providers, as well as the question of who should be providing the long-term care. In this review, we can see that patients with CRC have a set of unique needs to be addressed. Although their long-term comorbidities can be addressed the same way as a typical average patient, however, their cancer-specific supportive needs will have to be addressed as well. An SCP will have to identify and collate all these needs that are different from the regular patient. However, the best way to evaluate and address CRC patients’ specific needs is still unknown. With the publication of the IOM article, there has been much enthusiasm among the CRC survivors and their specialist care physicians. There are many organizations and hospitals that have put in place their own self-designed care plans not just specifically for CRC but for many other cancer types as well such as prostate cancer and breast cancer. There is a lack of objective data that evaluate the long-term effects and benefits of these selfcare plans, as well as the sustainability of these programs. It will take a lot of commitment from the patient, as well as the specialists care physicians, and the primary care physicians to implement such a care plan. In addition, as SCPs have only recently been established and implemented, we do not have sufficient information to evaluate these programs in the long run. Expert Rev. Anticancer Ther. 15(6), (2015)

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Addressing the needs of colorectal cancer survivors: current strategies and future directions

Finally, cancer is a disease that affects patients internationally. As such, there are many different factors that need to be considered while planning a SCP such as health care systems, institutions national healthcare structures, the geographical limitations and the cultures in different societies. This means that there is not a one-size-fits-all colorectal SCP that can be implemented universally. Each country needs to find his or her own model to be adapted for the nation’s needs. As each healthcare system personalizes their own SCP, there are a few key questions that will have to be addressed. Resource allocation is important and hence the design of program resources will have to be addressed, especially the allocation of time and staff expertise. Second, future research should be done to objectively assess and evaluate the program and the care plan in terms of their short- and long-term benefits. Last but not least, clinicians and administrators will need to continuously innovate to explore different avenues and ways to carry out these care plans in this particular era where patients are more educated and they expect to be more socially engaged.

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participation of individuals, communities and healthcare providers in a proactive way. A SCP would help in addressing the preemptive needs of patients with CRC as they embark on their life after cancer treatment. It is a collaborative effort between both healthcare providers and patients in obtaining a relationship that would truly be patient-centered. While further research on the administration and the long-term effectiveness of colorectal SCP can be done, we should be encouraged by the enthusiasm and participation that has been seen so far. There are many significant barriers to the implementation of survival care plan in CRC, including the intense resources that are required. The long-term effect on psychological, oncological and resource outcomes can and should be evaluated. It is unlikely that one model will suit all patients; however, with the possibility of both hard written and possibly electronic care plans that can be assessed with convenience and minimal resource allocation, the potential for SCPs is obvious. Research addressing all these variables over a long period of time is much needed.

Five-year view

In 2009, The NIH came out with a program of action based on the ‘4P’s of Medicine’: medicine that will be more Predictive, Personalized, Preemptive and Participatory. Their eventual goal is to further their understanding of the fundamental causes of diseases at their early stages to predict how, when and in whom a disease will occur, to target treatment on a personalized basis, to preempt disease before it occurs by using the

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

Key issues .

Survivorship care plans (SCPs) are meant to facilitate holistic care. Implementing a structured program for detection and surveillance will assist physicians and surgeons in detecting relapsed disease, other noncancer disease progression and assisting the treatment and management of chronic and late complications of the initial primary treatment.

.

Compliance with post-treatment surveillance for patients with colorectal cancer is key for early detection of metastasis.

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Survivorship care provides an opportunity to encourage a healthy lifestyle. Exercise and activity have been associated with a reduced risk of cancer recurrence and mortality.

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SCPs involve a collaborative multidisciplinary effort between multiple healthcare providers to empower patient involvement in health decision-making, translating to greater satisfaction with treatment choices; improved coping mechanisms during the diagnosis, treatment and post-treatment phase; reductions in anxiety and mood disturbances; and improved communication with family members.

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The concept of personalized medicine with chronic use of selected drugs (e.g., aspirin) informed by the molecular pathology of the tumor could also have a role in survivorship care.

Europe from the late 1980s to the early 21st century: the EUROCARE study. Int J Cancer 2012;131(7):1649-58

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