Survivorship Care in the Era of Immuno-Oncology

The end of 2020 marks the close of the first decade in which immuno-oncology (IO) has become a treatment option for many patients with cancer. Groundbreaking progression-free and overall survival effects have been realized because of this new treatment modality. Cancer care team members have accumulated knowledge that has provided valuable insight into all aspects of IO care, including treatment selection, treatment delivery, and toxicity recognition and management. Yet while the positive impacts of IO therapy are remarkable, the era of IO has also ushered in new challenges. The efficacy of IO has led to a growing population of patients living with and beyond cancer. This has challenged original concepts of survivorship care, starting with the very definition of “survivorship.” Historically, patients entered survivorship care upon completion of their treatment. The traditional aims of survivorship are to improve communication, simplify care coordination, and optimize patient education. Simply put, the goal is to give patients and their providers the tools necessary to safely transfer a patient’s care from the oncology team to the primary care team.

Cancer survivorship programs have expanded during the past two decades to serve this goal and provide optimal patient care from oncologists and primary care physicians working together. This aim was supported by the 2006 Lost in Transition publication from the Institute of Medicine¹ (now the National Academy of Medicine), which has guided the model of survivorship that many cancer programs have adopted. Cancer survivorship care plans were developed and discussed with patients almost exclusively at the end of treatment.

With the advent of IO, the shortcomings of this survivorship model became obvious. The idea that a person would successfully complete treatment and then move to a surveillance and monitoring phase while anticipating complete resolution of previously experienced side effects and toxicities became an unrealistic expectation. A cohort of patients began to experience late side effects for weeks or even months after completing their therapies. In addition, most patients who benefit from IO treatments do not experience a complete remission or “cure,” but will instead experience prolonged survival while continuing therapy. Although this is a success in cancer treatment overall, it brings significant challenges in caring for patients who have ongoing issues related to their treatment. These issues can be multifaceted, including physical, emotional, and financial, making these patients most in need of additional resources and care.

Existing cancer survivorship care programs should be adjusted to incorporate the concept of living with cancer, and/or living with long-term treatment-related toxicities. The concept of transferring a patient with cancer solely to primary care must be challenged. Rather, a multidisciplinary surveillance team should be assembled at the inception of treatment and continue into survivorship. The idea of a multispecialty IO toxicity team has been discussed, and its importance has been validated many times over. This multidisciplinary concept holds true all the way through survivorship and challenges current survivorship programs to become more efficient in communication, care coordination, and patient education.

As more new IO agents are approved for treatment—and a host of new combinations with new and old therapies also emerge— disease-free and overall survival rates will continue to climb, creating weeks, months, and hopefully years of added survivorship for our patients. We must meet the challenge of caring for these patients by creating multidisciplinary cancer survivorship programs that address the multifaceted needs of these patients.

References

1. Institute of Medicine and National Research Council. From cancer patient to cancer survivor: lost in transition. The National Academies Press; 2006.