Challenges in Survivorship & Comorbidities

Our clinic has a survivorship program as part of the standard of care we provide to our patients. I am the nursing team leader for this program. We provide an ongoing, collaborative effort in care for our patients who complete their chemotherapy. We provide their primary care physician a summary of their diagnosis and care received. Our care does not end when the chemotherapy ends. We continue to see our patients and work closely with their primary care providers.

There are many challenges in patients entering survivorship mode, and these challenges are even greater when the patient had comorbidities before the cancer diagnosis. Common comorbidities include coronary artery disease, hypertension, diabetes, COPD, and obesity. There are also less common chronic conditions that are considered comorbidities.

One particular group of patients comes to mind: women who have breast cancer. There has been some speculation and research about certain comorbidities with breast cancer. Obesity is the one that may actually have an impact on the development of breast cancer, the effectiveness of treatment, and the recurrence of breast cancer after chemotherapy is completed. The research about the link between obesity and breast cancer is in its infancy, but some of the preliminary findings are interesting and concerning.

Recently, a 45-year-old patient completed her chemotherapy for her stage I breast cancer, which was also found to be estrogen-receptor positive and progesterone-receptor positive. The HER2/neu status was negative. She had a bilateral mastectomy. There was no smoking or drinking history and no family history of breast cancer or any other type of cancer.

She completed four cycles of Adriamycin and Cytoxan, followed by four cycles of Taxol chemotherapy. She did experience grade 1 peripheral neuropathy. Fortunately, that subsided soon after her Taxol treatment was completed. She is now on tamoxifen for five years. She has a body mass index of 40, which is in the obese class III category, according to the World Health Organization. A long history of obesity is considered a comorbidity.

Counseling patients with the comorbidity of obesity is vital not only for their overall health, but also because current research is discovering links between obesity and cancer -- specifically, an increased breast cancer risk. Obesity can also diminish important advances in the fight against breast cancer, specifically by agents such as tamoxifen, which may not be able to target the estrogen they were intended to target. Instead, the agents may be deflected by the extra estrogen being stored in the body in visceral fat.

Research has highlighted that losing even 10 percent of body weight can reduce the concentrations of estradiol, leptin, and insulin in the body. These important reductions lead to reduced levels of proinflammatory cytokines. Less inflammation has been indicated as a possible cancer-reducing effect. Insulin is also being researched heavily as a possible cause of breast cancer. Hyperinsulinema prompts proliferative tissue abnormalities effecting DNA synthesis and cell proliferation, possibly prompting oncogenesis. More research in being conducted.

Survivorship contains myriad challenges for the patient and healthcare team. Comorbidities can make the survivorship challenges even harder. As nurses, we need the resources to learn more about what long-lasting effects chemotherapy has on survivors. I have read, reviewed, and re-read many national initiatives, articles, and studies on survivorship, but one of my go-to articles for introducing nurses to the full picture of survivorship is an article that was published by the American Journal of Nursing in April 2007. The article is called "The Cancer Survivor's Prescription for Living." I encourage everyone to get a copy of this article and keep it as a foundational piece for survivorship.

Once we understand what our patients have been through and some of the long-term side effects that are possible after chemotherapy, then we can better understand how to help our patients enter a survivorship mode that addresses these issues and any other ones presented by comorbidities.