Non Cancer Health Care and Health Maintenance

The IOM report suggested in its title that many cancer survivors are "lost in transition" and that the quality of care suffers when patients and providers do not know what is expected after primary treatment ends. While much of the focus of research and guidelines has been on cancer surveillance, non-cancer health care is equally as, and in many cases more important than surveillance. Most patients diagnosed with cancer today are expected to survive it.28 Studies have shown that potentially preventable conditions like heart disease and diabetes are actually the greatest threat to life for many of these patients.83,84 As a result, despite the fact that a diagnosis of cancer tends to subjugate all other concerns for a while, preventive care and the management of other medical conditions may actually be more important in the long run.

The end of primary treatment for cancer has been called a "teachable moment."85 This recognizes that with significant events in a patient's life, there is the opportunity to have a greater impact on health behaviors with programs that have been shown to help change risk behaviors than at other times. As a result, the survivorship care plan should include specific recommendations on lifestyle issues such as diet, exercise, smoking, and immunizations.

While studies have shown cancer survivors usually have more medical contacts than people without a history of cancer,86 there is also evidence that they may not always receive the same quality of care for other medical problems such as diabetes or chronic lung disease.87 A blinding focus on the prior malignancy or nihilism about the prognosis may leave cancer patients' other medical issues relatively ignored. The quality of routine care for cancer survivors has been shown to be related to their level of engagement in the health care system.86,87 Patients followed exclusively by primary care physicians are less likely to undergo recommended surveillance for their cancer, while those who use oncologists as their primary care physicians may be less likely to receive recommended non-cancer care. Patients followed by both types of physicians consistently receive the highest quality care. One explanation for these observations is that there may be lack of clarity around the relative roles primary care and specialist physicians will play in a survivor's care. Alternatively, it is possible that there is a disconnection between the expectations of care among survivors and their various health care providers. Patients and primary care physicians may assume that cancer specialists are delivering care that they are not (e.g., screening for other cancers, checking lipid levels along with the tumor marker). Some patients may be looking to their specialist physician for primary care but the specialist may not be aware of it. In fact, a large survey of oncologists found that they generally do not want to take on that role.88 Similarly, PCPs may assume either that there is still an oncologist involved when there may not be, or that that oncologist will assume responsibility for all cancer screening, not just surveillance of the original cancer.

The transition off of primary cancer treatment is also a second opportunity to consider whether genetic assessment might be necessary. During an initial consultation, when taking the family history, a potential genetic predisposition may be detected. However, the patient may not pursue referral to a genetic counselor at that time because they are so overwhelmed by the new diagnosis of cancer and dealing with the treatment they will have to embark upon. The completion of treatment is another opportunity to review this issue and consider making a referral. The genetics of breast, ovarian, and colorectal cancers are best understood, but increasingly associations with other cancers such as pancreatic cancer and melanoma are being recognized, although screening recommendations are not well developed. Patients may be offered participation in clinical research looking to better define surveillance strategies for high-risk patients (e.g., EUS screening for patients with heritable risk of pancreas cancer). Documentation of a genetic predisposition to cancer could affect not only recommendations for family members, but surveillance recommendations for the patient. For example, interval cancers are more common among patients with Hereditary Non-Polyposis Colorectal Cancer and so surveillance colonoscopies should be more frequent.

Supplements For Diabetics

Supplements For Diabetics

All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.

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