8.6 Cancer Prevention, Survivorship & Psychosocial Care

1. Cancer Prevention

Smoking cessation

The single highest-yield cancer prevention intervention available. Tobacco causes cancer of the lung, oral cavity, pharynx, larynx, esophagus, stomach, pancreas, liver, colorectum, kidney, bladder, cervix and myeloid leukemia. Risk declines steadily after quitting, though it does not return fully to that of a never-smoker.

Pharmacotherapy plus behavioral support is more effective than either alone. Varenicline has the highest quit rates, followed by combination nicotine replacement (a long-acting patch plus a short-acting form) and bupropion. Advise cessation at every visit, and note that e-cigarettes are not an approved cessation therapy although some patients use them for that purpose.

Chemoprevention and vaccination

• HPV vaccination prevents cervical, anal, oropharyngeal, vulvar, vaginal and penile cancer.
• Hepatitis B vaccination prevents hepatocellular carcinoma.
• Treating hepatitis C reduces but does not eliminate hepatocellular carcinoma risk, so surveillance continues in cirrhotic patients after cure.
• Treating Helicobacter pylori reduces gastric cancer risk.
• Tamoxifen, raloxifene or an aromatase inhibitor reduces breast cancer incidence in selected high-risk women, and this discussion is a recognized quality measure.
• Aspirin reduces colorectal cancer incidence, but is not recommended solely for that purpose because of bleeding risk.

Environmental and occupational carcinogens

An occupational history is part of the cancer risk assessment and is explicitly represented in the blueprint through the occupational medicine cross-content area.

Inherited cancer risk

Features that should trigger genetic evaluation:

• Cancer diagnosed at an unusually young age
• Multiple primary cancers in one person
• Bilateral disease in paired organs
• Several close relatives with the same or related cancers
• A known pathogenic variant in the family
• Cancers with strong syndromic associations — male breast cancer, ovarian cancer, medullary thyroid carcinoma, pheochromocytoma, retinoblastoma

Genetic testing requires counseling before and after, because results affect relatives, carry psychological weight and can be misinterpreted — a variant of uncertain significance is not an actionable positive result.

Lifestyle

Maintaining a healthy weight, physical activity, limiting alcohol (a cause of oral, pharyngeal, esophageal, liver, colorectal and breast cancer, with no established safe threshold for breast cancer), limiting processed and red meat, and sun protection.

2. Cancer Survivorship

The blueprint enumerates surveillance and second malignancies as the subtopics. With survivorship now measured in decades, general internists provide most of this care.

The survivorship care plan

Every survivor should have a written summary containing:

1. Diagnosis, stage and treatments received — including cumulative anthracycline dose, radiation fields and doses, and all surgeries
2. A surveillance schedule for recurrence
3. Expected late and long-term effects
4. Screening recommendations for second cancers
5. Clear division of responsibility between oncology and primary care

The treatment details matter enormously, because late-effect risk is exposure-specific. A survivor who cannot say whether they received an anthracycline or where the radiation ports were cannot be risk-stratified.

Surveillance for recurrence

The governing principle is that intensive imaging and tumor marker surveillance rarely improves survival in solid tumors, and generates false positives, radiation exposure and anxiety. Most solid tumor surveillance is history, examination and targeted testing at guideline intervals.

Exceptions where surveillance genuinely changes outcomes include colorectal cancer (carcinoembryonic antigen and colonoscopy, because resectable liver metastases are curable), testicular cancer, and breast cancer (annual mammography of remaining breast tissue).

Second malignancies

Driven by treatment, shared risk factors and genetic predisposition.

The chest radiation rule is heavily tested: a woman treated with mantle or chest irradiation for Hodgkin lymphoma as a young adult carries a breast cancer risk comparable to a BRCA carrier and requires intensified surveillance decades later.

Late effects by system

• Cardiac — cardiomyopathy, valvular disease, accelerated coronary disease, constrictive pericarditis
• Endocrine — hypothyroidism after neck radiation, hypogonadism, infertility, premature menopause, adrenal insufficiency
• Bone — osteoporosis from androgen deprivation, aromatase inhibitors, corticosteroids and premature menopause
• Neurocognitive — cancer-related cognitive impairment (chemobrain), peripheral neuropathy
• Immune — functional asplenia after splenectomy or splenic irradiation, requiring vaccination and fever precautions
• Psychological — depression, anxiety and fear of recurrence, the most commonly reported unmet need among survivors

Fertility preservation must be discussed before treatment, not after, because the opportunity is lost once gonadotoxic therapy begins.

3. Psychosocial and Financial Considerations

A separately enumerated blueprint subsection, reflecting recognition that these determine outcomes as much as tumor biology.

Psychosocial

Distress screening is a standard of accredited cancer care. Depression is common, under-recognized and under-treated, and it is not a normal or inevitable response to cancer that should be left alone. Somatic symptoms — fatigue, appetite loss, sleep disruption — overlap with cancer and its treatment, so diagnosis should weight anhedonia, hopelessness, worthlessness and suicidal ideation more heavily. Depression reduces treatment adherence and quality of life, and treating it improves both.

Early integration of palliative care alongside cancer-directed therapy improves quality of life and mood, and in some trials survival, while reducing aggressive end-of-life care. It is not the same as hospice and does not require stopping treatment.

Financial toxicity

The adverse effect of treatment cost on wellbeing and outcomes. It is common, largely invisible unless asked about, and clinically consequential:

• Patients ration or abandon medication because of cost, with measurably worse outcomes
• Delay or skipping of follow-up appointments and imaging
• Bankruptcy risk is elevated among cancer survivors, and financial insolvency is associated with worse survival
• Employment disruption compounds loss of insurance

What the internist can do: ask directly about affordability, because patients rarely volunteer it; involve social work and financial navigation early; prescribe generic or lower-cost equivalents where clinically equivalent; connect patients to manufacturer assistance and foundation programs; consolidate appointments to reduce travel and lost work; and document work restrictions and disability accurately.

Caregiver burden is a recognized companion problem, with high rates of depression and financial strain among caregivers themselves, and it should be assessed rather than assumed.