Depending on the patients and the setting, practices can adopt various models to deliver survivorship care.
At CAVHS, cancer survivors are followed by an oncologist for their yearly examinations. This model is an illness model rather than a wellness model. A multidisciplinary clinic model can be initiated at CAVHS with the help of palliative care; complementary and alternative medicine for pain management; psychologists, chaplain services, and social workers for distress management; and coordination of survivorship care.
Implementation Barriers
There are many barriers to implementing SCPs, including time required by the providers to complete SCPs, inadequate reimbursement for the time and resources required to complete SCPs, challenges in coordinating care between survivors and providers, and lack of compatibility of the existing template with the electronic health record (EHR). 7-10 A study regarding the barriers to implementation of SCPs, conducted at 14 NCI community cancer centers, demonstrated that the most common barrier is lack of personnel and time required to complete SCPs. The most widely used strategies was the use of a template with prespecified fields and delegating the completion of SCPs to one individual. 12
Long-Term Complications for Survivors
Cancer survivors experience the physical and psychosocial effects of cancer treatment and have a very high risk of recurrence and second primary cancers. Common chronic AEs include fatigue, pain, neuropathy, infertility, sexual dysfunction, hypothyroidism, organ dysfunction, and urinary and bowel incontinence. In addition, patients also experience psychological AEs, including anxiety, depression, posttraumatic stress disorder, and sleep disturbances. Because of the AEs, cancer survivors have difficulty obtaining employment and insurance. 1,5
Fatigue
Fatigue is the most common AE in cancer survivors. 1 It may develop during treatment and persist for years. It is related to chemotherapy, radiation, surgical complications, depression, and insomnia. 1 It is underrecognized and often untreated. It is important to assess and treat underlying comorbidities such as anemia, hypothyroidism, pain, depression and insomnia. 13,14 Pharmacologic therapy with central nervous system stimulants and antidepressants have not shown any benefit. 15 Studies on modafinil and armodafinil are ongoing. 15 Exercise, treating underlying depression, sleep hygiene, behavioral and cognitive therapy, and yoga and mindfulness management of distress can help in treating fatigue. 13 Meta-analyses showed that physical exercise helped reduce cancerrelated fatigue. 15 A randomized controlled trial demonstrated that yoga led to significant improvement in fatigue in breast cancer survivors. 16 Hence, it is important for providers to recognize and treat cancer-related fatigue and encourage patients to exercise. 17
Psychological Adverse Effects
Cancer survivors also experience psychological AEs such as anxiety and depression because of the cancer diagnosis and the uncertainty of the outcome and the fear of relapse. Veterans may be at a higher risk of psychological AEs because of underlying mental illnesses. Counseling about the disease, psychotherapy interventions, and a mindfulness approach are recommended to treat anxiety and depression. 14 The CAVHS cancer program has developed a mindfulness program as a multidisciplinary approach to manage psychological AEs. 18
Sexual Dysfunction
Many patients may experience sexual dysfunction and infertility as a result of endocrine treatments, chemotherapy, radiation, and urologic and gynecologic surgeries. 1 Over half of prostate cancer and breast cancer survivors report sexual dysfunction. Despite its high prevalence, sexual dysfunction often is not discussed with patients due to reluctance to discuss, lack of training, and lack of a standardized sexuality questionnaire. 19 A brief sexual symptom checklist for women can be used as a primary screening tool. It is also recommended to screen for treatment-related infertility. Patients with sexual dysfunction should undergo screening for psychosocial problems such as anxiety, depression, and drug and alcohol use and treatment as these can contribute to sexual dysfunction. 1
