Between 30 and 50% of us will have a cancer diagnosis during our lifetime and, increasingly, cancer is becoming a long term condition. In the UK, 2.5 million people live with and beyond cancer.

Of these, it is estimated that 625,000 have a health problem or disability as a result of cancer and its treatment. This can be highlighted most clearly in data from survivors of childhood cancer. There is now an 80% 5-year survival rate. These data highlight the great steps taken in achieving a cure: we can now expect good outcomes, and success. However, there is a downside. By the age of 50, survivors have a cumulative incidence of significant/fatal health conditions of some 53%: this is more than double the incidence in matched sibling controls.¹

For example, in female survivors of haematopoietic stem cell transplant 10 years after treatment, over 80% have premature ovarian insufficiency. There is also a two- to fourfold increase in cardiovascular disease, and significant rates of dyslipidaemia, hypertension and diabetes.

 

A ROLE FOR ENDOCRINOLOGISTS

So what has this got to do with endocrinology? Quite a lot, in fact. For me, as always, it started with my patients. To look after them as well as possible, I needed to understand the details and consequences of their cancer treatments. If we consider the multiple types of cancer treatment used, we can easily see that there is a large impact on the endocrine system.

Two of the ‘big’ cancers, breast and prostate cancer, include hormone therapies rendering patients hypogonadal. This often leads to symptoms that are difficult to manage and an increased risk of osteoporosis. Radiotherapy for head and neck cancers causes hypopituitarism. Chemotherapy, in particular alkylating agents, can cause hypogonadism. Newer biological agents (in particular immune checkpoint inhibitors) can cause hypophysitis and thyroiditis.

Importantly, as endocrinologists, we often take on a significant role in delivering general medicine in our hospitals. We may therefore encounter patients with heart failure as a result of chemotherapy (anthracyclines), fractures as a result of pelvic irradiation, or patients sadly presenting with a second malignancy as a consequence of their initial cancer treatment. In my clinics, I manage survivors of childhood malignancies, in particular those of the head and neck, and haematological malignancies, as well as caring for patients with endocrine malignancies and neuroendocrine tumours. However, I increasingly encounter cancer survivors of all types.

 

CURRENT PROVISION OF CARE

Services handling consequences of cancer treatment, or late effects, are currently not widely established within the NHS. The most robust systems are in place for survivors of haematological malignancies, in particular haematopoietic transplants. Otherwise, long term care is inconsistent or not available.

Even where services are present, there remain obstacles to optimal care. Whilst survivors of childhood malignancies often have a cancer treatment summary which lists the types and dose of chemotherapy and radiotherapy that were administered, too often this is not available for adult survivors. This is particularly the case if treatment took place several years previously, in a different institution or a different region.

The apparent care gap is not in service delivery alone. Many physicians are not aware of the impact of cancer treatments on long term health, and the consequences of cancer treatment are not covered widely in undergraduate or postgraduate curricula.

 

ANTICIPATION MATTERS

So, while we can now expect good outcomes in much of the cancer we deal with, with this comes a need to anticipate managing the consequences of the disease and its treatment. One cannot go without the other. What can we do as endocrinologists to improve the experience and outcome for our patients? The answer is to ‘start simple’ and ask:

1. Does this patient have a cancer diagnosis?
2. What type of cancer?
3. What treatment did they have?

 

IN SEARCH OF GUIDANCE

Along with others, I am currently compiling guidance on the endocrine consequences of cancer treatment, with recommendations on what we should be doing for our patients. These will be published in Clinical Endocrinology and will also be available on the Society for Endocrinology and Macmillan websites initially.

Colleagues in cardiology and gastroenterology are ahead of the curve, and have already published guidance and patient information resources.^2,3 We are also working with Macmillan to produce endocrinology guidance for GPs and patient information. This is an exciting opportunity to reach out to millions of cancer survivors and their healthcare professionals.

Ultimately, all cancer patients should have treatment summaries and access to surveillance/management pathways across primary, secondary and tertiary care. Electronic processes should be available to ensure all healthcare professionals can access appropriate clinical guidance when they come across cancer survivors in their clinical practice. Models of care need to be developed locally: these should break down boundaries between primary, secondary and tertiary services and also work across specialties within hospitals.

But we need an important reality check: all this needs to be achieved in a healthcare environment of increasing demand and decreasing financial resources.

Before we all get overwhelmed with a sense of impending doom, we can all make small steps in our own practice. As a starter, how about, ‘Think cancer … and think consequences of cancer treatment'?

Helen Simpson

Cambridge University Hospital NHS Foundation Trust

 

REFERENCES

1. Armstrong GT et al. 2014 Journal of Clinical Oncology 32 1218–1227.
2. Macmillan Cancer Support 2015 Managing heart health during and after cancer treatment.
3. Andreyev HJN et al. 2011 Gut doi:10.1136/gutjnl-2011-300563.