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Baker et al. J Cancer Metastasis Treat 2020;6:24 I http://dx.doi.org/10.20517/2394-4722.2020.36 Page 3 of 12

is concerning as this is precisely the population of cancer survivors that demonstrates manifestation of
[12]
CAD. Chow et al. developed a prediction model to account for treatment-related risk factors and age at
diagnosis based on 5-year cancer survival, but did not include hypertension, dyslipidemia, and diabetes.
Conventional risk factors (obesity, hypertension, dyslipidemia, and diabetes) have been characterized
[21]
by some as non-cancer related issues . However, we now have evidence that obesity, hypertension,
diabetes and lipid abnormalities can and do result from cancer therapies. The adolescent who has a life-
long disability from an amputation-sparing knee reconstruction should expect decreased mobility and
an increased risk of chronic pain, depression, and obesity as a consequence of cancer diagnosis and
care. In the absence of guidelines for the timing and frequency of surveillance of chronic conditions and
management of CAD risk factors, oncology providers are left with inadequate knowledge about (what may
be perceived as) non-oncology care, and primary care providers are left with inadequate knowledge about
[22]
cancer-specific follow-up care .
Adult survivors of childhood cancers, especially those treated with anthracycline chemotherapies, are
at a much higher risk of developing chronic conditions than other cancer populations [5,12,13] , making the
years post-treatment a crucial window of opportunity to diagnose and manage chronic health conditions.
Survivors of osteosarcoma and Ewing sarcoma have a 39-fold greater risk of acquiring severe, life-
[5]
threatening, and even fatal chronic disease(s) than their siblings . However, adherence to long-term
follow-up among adolescent and young adult survivors of childhood cancers sharply declines after
treatment ends, with primary care filling the healthcare gap for survivors of childhood cancers . A 2014
[23]
survey of general internists, published in the Annals of Internal Medicine, queried their comfort level and
preferences for caring for survivors of childhood cancers . A sizeable minority of respondents reported
[24]
being “somewhat comfortable” or “comfortable” caring for Hodgkin’s lymphoma, acute lymphoblastic
leukemia, and osteosarcoma patients (36.9, 27.0 and 25.0%, respectively), presumably due to the rarity
and treatment complexities of these diseases. A similar survey of 2,520 family physicians in the United
States and Canada confirmed that physicians were equally uncomfortable caring for survivors of Hodgkin’s
[25]
lymphoma, acute lymphoblastic leukemia, and osteosarcoma . This study further revealed that 81% of
respondents had cared for two or fewer survivors of childhood cancer in the preceding five years! It is
reasonable to posit that the majority of primary care physicians, including both pediatricians and internists,
will never see a patient with osteosarcoma in their practice. Knowledge of rare cancers accumulates with
the experience of the oncologist, and long-term care for survivors is no different. Thus, a model of care
tailored to the needs of these patients is necessary to prevent and manage chronic late effects.

To move the study of survivorship care forward we sought not to replicate the model of surveillance of
the long-term effects of anthracycline chemotherapy, but to actively intervene and treat those long-term
survivors for dyslipidemia, hypertension, obesity, diabetes, anxiety and depression. This model was created
in recognition that the patients being monitored for recurrence were developing chronic conditions which
were not being addressed in part due to lack of knowledge from primary care physicians or a paucity
of care, such as in the mental health care field. Recognizing that a “one size fits all” approach will not
adequately serve the heterogeneous population of cancer survivors, we piloted a survivorship clinic for
[26]
survivors of bone and soft tissue sarcomas led by a medical oncologist . This prospective cohort study was
conducted to identify and treat risk factors for CAD among adult survivors of sarcoma, including those
diagnosed as children, adolescents and young adults, and adults, as sarcomas occur at all ages. Risk factors
for CAD are well described and often modifiable [14,19] . We share preliminary data from the fifth year of this
prospective cohort study confirming a significant burden of chronic diseases in this population.

METHODS
Study population
To be eligible for enrollment in the survivorship clinic, survivors had to be 18 years or older at time of first
visit, be at least two years past active chemotherapy (adjuvant or neoadjuvant doxorubicin), and be willing